Risk-bearing provider organizations turn to advanced care management tools to close the gap between EHRs and HIEs.

Anyone who has undertaken a home improvement project knows they rarely progress – or turn out – as expected. The footprint of a new fixture is smaller than the one it replaces, revealing a damaged or unfinished surface. A leaky pipe is discovered when the bathroom vanity is updated. Wallpaper removal exposes a mildew problem.

Healthcare is currently undergoing significant refurbishing, and this improvement project is similarly fraught with unforeseen challenges. We’ve needed to construct new organizations, build new infrastructures and reconfigure staffing and resource models.

A lot of progress has been made – and a genuinely patient-centered, coordinated-care system is emerging. At the same time, vulnerabilities continue to be uncovered.

Thanks to government incentives, the mainstream industry has embraced technologies that automate clinical workflow with billing-supported encounter records (EHRs) and connect and integrate data from multiple sources (HIEs) to facilitate data mining for population health management. And yet there is gap between these technologies.

Risk-bearing organizations like accountable care organizations (ACOs) and those responsible for Medicare Advantage or managed Medicaid populations must also develop advanced care management workflows – such as case, disease, quality and utilization management – supporting a much broader care team that will ultimately be making decisions that impact quality and cost.

Historically, these components of the care cycle have been handled by payers. But as provider organizations assume greater risk within healthcare’s new paradigm, they must learn how to apply these cost and quality control levers across the entire care continuum – moving beyond the office visit or hospital stay. This can be accomplished, fortunately, while protecting and leveraging providers’ existing investments in traditional EHR and HIE technologies.

To help bridge the gap, risk-bearing entities can push care management technology that provides decision-support and workflow tools to physicians and the expanded care team at the point of care, while leveraging the availability of clinical, network and benefits information from various EHRs, claims databases and other sources. As a result, advanced care management services are fully integrated across the continuum to help drive down operational costs and manage financial risk for defined patient populations.

Any number of risk-bearing organizations are adopting an integrated care management strategy. AltaMed Health Services, the nation’s largest independent federally qualified community health center (FQHC) with 43 clinic sites and an extensive independent practice association (IPA), for example, is providing patient-centered healthcare in a collaborative environment for the safety net population in Los Angeles and Orange Counties. AltaMed and four other facilities formed the accountable care network (ACN) devoted to coordinating care and optimizing appropriate utilization for an expanding population of chronically ill and economically disadvantaged patients.

Among the innovations the ACN introduced is an integrated HIT solution that allows networked providers to manage utilization, quality performance benchmarking and other care management activities. With this communication pipeline and network reporting, clinicians will have improved access to patients in an outpatient, rather than inpatient, setting. This will result in a decrease in costly emergency department visits, hospital stay lengths and readmissions.

The Individual Practice Association Medical Group of Santa Clara County (SCCIPA) adopted a similar strategy with a coordinated care platform to facilitate in-network referrals and authorizations across its network of more than 850 independent physicians and other community-based provider organizations. The technology has streamlined physician and office staff workflow and improved care coordination, especially during care transitions. SCCIPA also integrated case and quality management features into its IT strategy, leading to significant cost savings and quality improvements.

Our current “healthcare improvement project” has not been without its share of surprises. But it has also produced an unprecedented level of innovation and strategic thinking. Upgrades like advanced care management processes can only help to make the finished product that much better.

About the author

David Murphy serves as the vice president, marketing, of Health Access Solutions, provider of the Web-based, multidisciplinary Coordinated Care Platform. To learn more, go to www.hasinc.com.

Coordinating care across networks
By: HMT Mag
The Source for Healthcare Information Systems Solutions