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Accountable Care Organizations

as research, reporting and actuarial, will need to develop ways to compare historical ICD-9 data to ICD-10 data. This comparison can pose a challenge, as the mapping between the new and old codes is not always one to one. There may be many ICD-10 codes that map to one ICD-9 code and vice versa and ICD-9 codes that do not map to ICD-10 codes. Once the comparison is completed, payers and ACOs could begin to build databases housing popu- lation health data. However, standards on the clinical side are evolving with the creation of the Nationwide Health Information Network (NHIN) CON- NECT and Direct projects.

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Enhanced eligibility Furthermore, the HIPAA transac- tions ASC X12 270 and ASC X12 271 can be used for checking eligibil- ity and benefi ts of a patient. Often times, providers check for eligibility or pre-authorizations for higher risk or higher cost procedures. However, ACOs could look at providing these checks for all types of patients to help determine the best treatment options. An ACO could provide more knowl- edge of prior patient treatments across multiple providers, best practices and outcomes. ACOs could help the pro- vider reduce unnecessary or redundant treatments, resulting in cost savings for payers and cash-fl ow improvements for providers.

Clinical decision support The information from checking eli- gibility and data sharing could simplify clinical decision support. For example, a primary-care physician could look at this type of data and make inferences as to when a patient had an annual physical in the last 12 months and send a reminder. An ACO may focus on quality measurement and manage- ment, including internal and external reporting, typically using quality mea- sures largely dictated by the payer. In

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many cases, these measures derive from evidence-based medicine and may correlate to clinical decision-sup- port tools that enable higher standards of measurement, evaluation and ad- justment of practices. ACOs will also need revenue cycle software that can manage new payment models, such as bundled and capitated payments, and that can help distribute shared savings. In some cases, ACOs may need payer data and analyses of linked payer/ACO data, including estimates of projected costs and other metrics for the ACO’s patient population. ACOs will need the ability to exchange data within the ACO and across providers (for example, hospitals, medical practices and post acute-care providers). This requirement involves standards-based internal interoperability and internal and external use of standards-based health information exchange (HIE).

Sustainable HIE model

An HIE that has the capability of storing clinical registries and encour- ages the use of e-prescribing could be well suited to assist ACOs in gather- ing data, which is a requirement for reimbursement and associated bonuses based on outcomes. HIEs and their an- ticipated analytics may drive the need for a more conclusive solution that is vendor neutral and patient-centric. The rapidly evolving technology and the inability of organizations to scale up with staff, facilities and infrastruc- ture may suggest that cloud delivery models create a way for enabling technology adoption at a lower cost, risk and shortest time to go-live. One of the keys to success will be using stra- tegic archiving and cloud services to provide the infrastructure behind the emerging data use and sharing models that are being driven by meaningful use and ACOs.

One approach to building the ACO infrastructure is to replace existing systems in favor of a single information system. A practical and cost-effective path may be to adopt HIE technol- ogy that enables ACO participants to


leverage existing information systems to exchange data across care locations, facilitate care collaboration, perform quality reporting and ensure all data for fulfi lling ACO objectives is captured. Some payers have created claims- based health records for their patients and have made these available to pro- viders via web-based system interfaces. These claims-based health records could provide details on care interac- tions for a patient and potentially be interfaced within the ACO to provide greater details – on prescriptions, treatments, surgeries, immunizations, etc. – to create a more complete lon- gitudinal patient record.

HIE-to-HIE collaboration and connectivity An ACO, a hospital HIE, a regional/ state HIE, a payer or a federal agency are all data sources with different policies and procedures. Each of these may interact with each other in the data-exchange ecosystem. In many instances, the role of a HIE is be a conduit for data and not the end point for data. Small providers and organi- zations may start with simple basic information-exchange requirements, perhaps through the Direct Exchange Project, to satisfy various meaningful- use standards. The Direct Project seeks to replace slow, inconvenient and expensive methods of exchange (such as paper or fax) and provide a future path to interoperability. Large orga- nizations and state HIEs may require nationwide information exchange, including information exchange with payers and/or federal agencies, such as The Centers for Medicare and Medicaid Services (CMS). This could be achieved through NHIN CON- NECT, an open-source software solu- tion that enables health information exchange – both locally and at the national level. CONNECT employs Nationwide Health Information Net- work standards and services to ensure that health information exchanges are compatible with other exchanges throughout the country. Furthermore,

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