Risk sharing is considered to be the centerpiece of healthcare reform. By bringing together hospitals, physicians and other providers under the umbrella of an accountable care organization (ACO) or shared savings program, the expectation is that highly coordinated care will be provided, preventing unnecessary duplication of services and improving quality of care. When shared-risk models successfully increase quality and reduce costs, stakeholders earn a share of the savings. Conversely, those not succeeding will be stuck with the costs of any investments made to improve coordination and will also be hit with financial penalties.

Success or failure is measured by an ACO’s performance on key metrics, focused mainly on admission/readmission rates and management of chronic conditions. While data and the analytics behind it are the driving forces pushing any successful risk-sharing model, we cannot ignore the importance of how information is collected and distributed at the point of care. How physicians, nurses, ancillary providers and others use that information significantly affects overall care outcomes and costs.

Considering that one department – health information management (HIM) – owns as much as 80 percent of the data flowing through healthcare organizations, it would be a significant risk to exclude it during the planning and execution of ACOs, shared savings programs and other risk-sharing care models. HIM should be front and center when designing the business model and data governance policies to ensure the right data is being shared at the right place and at the right time – and that the right analytics are being performed to achieve clinical and financial objectives.

The reason I advocate so strongly for HIM’s involvement is because HIM leadership already owns several critical elements impacting success. These essentials include the clinical integration required to make meaningful, complete and accurate patient information available to providers at the point of care, the documentation required by providers and all the data that affects reimbursement. HIM is the first line of defense for providers using medical records or systems that host patient information; it has the trust of the providers, which can be leveraged to maximize provider behavior modification.

When that ownership is taken into consideration, it becomes clear HIM needs to take the lead in shaping how an ACO uses clinical guidelines and documentation mandates to maximize provider adoption. HIM also owns the back-end processes influencing ACO success rates, such as ICD-10 and concurrent coding reviews. These are important avenues for implementing the clinical documentation improvements impacting the quality of data shared by providers – data that is integral to improving care coordination and reducing costs across care settings.

However, before HIM can truly be effective in a leadership position, several skill gaps must be closed. The first is a lack of understanding of analytics tools and techniques and formal knowledge of business modeling, in particular value-chain and workflow modeling. HIM leadership typically has an exceptional level of expertise in these areas. However, it does not seem to be shared by mid-level practitioners. AHIMA now offers a professional certification to assist with analytics, which holds promise for closing this particular gap.

Another area where HIM falls short is the ability to evaluate the severity of case mix for a specific provider for whom a quality measure is reported. This is the very basis of ACOs and risk-bearing contracts. However, while HIM is closest to the information, and has the capability and should be the best at that evaluation, I am not convinced it is currently positioned as the go-to expert. Finally, knowledge of point-of-care usability and instructional design will also be highly beneficial to HIM managers.

These skills gaps are easily addressable. Once they are, HIM must step up – forcing its way to the table if necessary – and utilize its unique familiarity with patient data, reimbursement data and provider behavior to influence real change in the cost and quality of healthcare under risk-sharing models.


About the author

Subbu Ravi is COO of Amphion Medical Solutions