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Accountable Care Organizations

Eight reasons payer interoperability and data sharing are essential in ACOs

Interoperability standards could be a prerequisite to measuring care. By Shefali Mookencherry, Hayes Management Consulting

exchanges (HIEs) may be one component. So, what makes one think of data sharing as important? Beginning this year, providers became eligible for federal funding to help them meet benchmarks called meaningful use (MU) standards. Data sharing is an important part of the MU standards. MU criteria could allow an ACO to perform effectively by way of improving outcomes, managing population health and de- livering personalized medicine. Also, the perception is that HIEs will facilitate meaningful use and enable health plans to interact directly with providers at the time of care and to provide automated alerts, reminders and other guidance based on population health data.


Interoperability standards could be a prerequisite to mea- suring care. Interoperability standards defi ne the vocabulary, protocols and presentation features of healthcare information in order to achieve interoperability between systems. One thing to note here is that the defi nition of “interoperability” varies by organization. Several standards bodies are in the process of developing or may have developed interoperability standards for various types of information. Some of the la- tency in the general adoption of standardized communication has been due to the various competing standards developed by different standards bodies. There has been an increasing amount of work to build bridges between the standards (translations). This is being done so that healthcare mes- sages/documents created in one standard can be translated into another without the loss of information integrity. For example, Health Level Seven International (HL7) is a global authority on standards for interoperability of health informa- tion technology with members in over 55 countries. Listed below is an example of HL7’s V2 Messaging

standard: HL7’s Version 2.x messaging standard is the workhorse of electronic data exchange in the clinical domain and argu- ably the most widely implemented standard for healthcare

16 January 2012

s part of healthcare reform, accountable care or- ganizations (ACOs) are a growing foundation for the future of healthcare. However, what will ex- ist within that foundation? Health information

in the world. There have been seven releases of the Version 2.x standard to date. The HL7 standard covers messages that exchange information in the general areas of:

• Patient demographics; • Patient charges and accounting; • Patient insurance and guarantor; • Clinical observations; • Encounters including registration, admission, discharge and transfer;

• Orders for clinical service (tests, procedures, pharmacy, dietary and supplies);

• Observation reporting, including test results; • The synchronization of master fi les between systems; • Medical records document management; • Scheduling of patient appointments and resources; • Patient referrals, specifi cally messages for primary care referral; and

• Patient care and problem-oriented records.

Interoperability standards could be a fundamental component within an ACO model. Hence, is it essential to have payer interoperability and data sharing integrated in an ACO model? Simply put, yes. As a result of the clinical encounter, clinical and business processes incur many data cycles that bear opportunities for cost savings and improved quality of care.

Listed below are eight reasons why it is essential to have payer interoperability and data sharing in an ACO model:

1. Importance of payer role; 2. Member’s health lifecycle; 3. Standardization of billing and claims operations/manage- ment;

4. Clinical decision support; 5. Enhanced eligibility; 6. Cost savings; 7. Developing a sustainable model of an HIE; and 8. HIE-to-HIE collaboration and connectivity.


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