1.800.360.0603

GE Healthcare Camden Group Insights Blog

Why ACOs Must Capture Clinical Data to Truly Drive Care Improvement

Posted by Matthew Smith on Aug 28, 2013 12:58:00 PM

By Daniel J. Marino, President & CEO, Health Directions

ACO, Accountable Care OrganizationAs ACO leaders shift their attention from high-level planning to working out the nuts and bolts of operations. The main challenge is learning how to manage performance under Medicare’s 33 quality measures. Success or failure will be determined by how well an ACO can create effective change in clinical processes.

The first priority is to develop processes for capturing the data needed for reporting. But reporting quality data is just the tip of the iceberg. The underlying aim of the quality measures is to provide more coordinated care. Caregivers will need to adopt new behaviors and practices, and ACOs will have to create tools to support new clinical behaviors and actively manage care coordination. This in turn will call for a broader approach to healthcare information. ACOs will need to capture clinical data not only to report measures but also to drive care improvement initiatives.

How Can ACOs Create Targeted Change at the Clinic Level? 

Leading organizations are taking a systematic approach—translating each of the 33 quality measures into clinical processes, programs and information systems that drive reporting and improve clinical outcomes.

Case in Point

Operationalizing Measure 12. One of the core strategies of accountable care is to reduce errors and improve patient outcomes through better medication management. ACO Measure 12 supports this goal by requiring organizations to report the percentage of patients who receive timely medication reconciliation after discharge from an inpatient facility. While the measure is straightforward, the underlying problem is complex. Patient hospitalizations usually involve several medication changes, and hospitals do not consistently communicate discharge medications to primary care physicians and other treating providers. Physicians are often unable to determine the rationale of discharge medications and may have a hard time incorporating new drugs and doses into revised care plans. Disjointed medication management—especially for patients with multiple comorbidities—results in post-discharge complications and hospital readmissions.

Considering the full scope of the problem, what does an ACO need to do to operationalize Measure 12? Start with the patient’s needs at discharge and work backwards. The following example illustrates one possible approach:

Clinical Behaviors

In most organizations, providers will need to put more emphasis on consistently providing medication reconciliation for recently discharged patients. Nurses may need to adopt new processes for documenting and verifying current medications, and physicians will need to incorporate medication reconciliation into standard practice patterns. All providers will need to document medication reconciliation correctly, which may require additional training.

Clinical Data

To perform medication reconciliation in the post-acute clinic, physicians and nurses will need consistent access to discharge medication lists. Create interfaces for pulling discharge medications by drug name, dose, frequency and route from the hospital information system. Building a discharge medication list may involve establishing electronic feeds from hospitalist, specialty consultant and discharge planner notes.

Supporting Programs

In addition to processes and information systems that are directly involved in operationalizing Measure 12, an ACO will need to create programs that support new behaviors and drive performance improvement. Organizations might implement one or more of the following:

  • Proactive collaboration: Hospitalists could spearhead an effort to proactively coordinate discharge planning with post-acute physicians.
  • Direct physician contact can simplify medication reconciliation for primary care providers and help prevent drug-related complications.
  • Nurse navigators: New processes are not enough to ensure all patients receive timely medication reconciliation. Someone needs to quarterback the overall system. An ACO could assign nurses to identify patients in post-discharge and schedule appointments with primary care physicians. Create a trigger within the hospital information system to alert a nurse navigator when a patient has been discharged. Use claims data to identify beneficiaries who leak out of the system (e.g., a patient who is hospitalized while vacationing out of state).
  • Patient outreach: Nurse navigators could use contact management software to communicate key information to patients during the post-discharge period. Healthcare-specific contact software exists, but many organizations have simply adapted business contact tools to the healthcare environment. Home health nurses could facilitate medication reconciliation for the most complex patients and work with patients to ensure medication compliance.

The system described above is only one way to operationalize Measure 12. Several effective approaches are possible. The important point is to develop a strategy that aligns clinical operations with the goals of the measure, with a comprehensive system of interventions built on care plans, clinical roles, efficient communication and electronic exchange of information. Implemented appropriately, a comprehensive strategy will help caregivers achieve advanced performance outcomes and higher quality patient care following hospitalization.

Tools and Techniques

Clinical process translation is a huge task. ACOs need to establish new work processes, create new data feeds to populate the clinical disease registry, and develop new support programs for each of the 33 quality measures. Ideally, all new processes will be rolled up into a comprehensive care management program for ACO beneficiaries.

One approach is to develop an Acute-to-Ambulatory Transition Program that coordinates medication reconciliation efforts with other care initiatives. The program could identify patients who have been admitted to an inpatient facility and take steps to address the risks that lead to preventable readmissions. Specific program elements could include better efforts to create and communicate discharge care plans. Contact management tools could be used to communicate with primary care physicians and send education materials and appointment reminders to patients.

How can an ACO manage a patient population across multiple care programs? The most useful tool is the care gap report. Populated from the ACO’s clinical disease registry, care gap reports identify discrepancies between care protocols and the actual care delivered to specific patients. ACOs can use care gap reports to track their performance on both quality measures and the clinical processes that support them. For instance, ACOs need to improve the health of diabetic patients through better hemoglobin A1c control (Measures 22 and 27). Providers could use a care gap report to flag patients who have not had an HbA1c reading in the last three months. Nurse navigators or other program staff could then contact patients to schedule lab work and guide appropriate follow-through.

Care gap reports can tie together several measures to enable more efficient interventions. For example, if a patient has been identified to come in for an HbA1c blood test, the report could also prompt a flu shot (Measure 14), pneumococcal vaccine (Measure 15) and other preventive health services. The system could also be configured so that care gap reports trigger alerts within the ambulatory EMR, prompting physicians and nurses to deliver protocol interventions. As the Shared Savings Program transitions from pure reporting to performance measurement, care gap reports will become a critical tool not only for meeting quality measures but for driving clinical process change and managing costs. Process improvement dovetails with current efforts to operationalize the ACO measures. Both follow an evolution:

  • First, capture the clinical information elements needed to drive the measures.
  • Second, aggregate the data elements to enable analysis.
  • Third, interpret the data to drive improvements in clinical workflow and care coordination.

Clinical process improvement will ultimately be the main driver of ACO performance and profitability. To the extent that ACOs can do a better job of managing care for high-risk and transitional-risk patients, they will dramatically improve clinical and financial outcomes.
Ongoing Performance Gains. A systematic approach to operationalizing the 33 quality measures will help organizations ensure that clinical process workflows support care management goals. Process translation teams should include strong representation from clinical providers and administrative staff, including physicians, nurses and IT technicians. Multidisciplinary collaboration is the key to creating clinical processes that not only enable reporting, but allow an ACO to achieve ongoing performance gains by controlling costs and improving patient outcomes.

Topics: Accountable Care, ACO, Clinical Integration, Medicare, Clinically Integrated Care, Clinical Process, 33 Quality Measures, Accountable Care Organizations, Clinical Care, Care Improvement

Adopting ACO Change: Turning Quality Measures into Clinical Processes

Posted by Matthew Smith on Mar 18, 2013 10:05:00 AM

By Daniel J. Marino, President & CEO, Health Directions

ACO, Accountable Care OrganizationAs ACO leaders shift their attention from high-level planning to working out the nuts and bolts of operations. The main challenge is learning how to manage performance under Medicare’s 33 quality measures. Success or failure will be determined by how well an ACO can create effective change in clinical processes.

The first priority is to develop processes for capturing the data needed for reporting. But reporting quality data is just the tip of the iceberg. The underlying aim of the quality measures is to provide more coordinated care. Caregivers will need to adopt new behaviors and practices, and ACOs will have to create tools to support new clinical behaviors and actively manage care coordination. This in turn will call for a broader approach to healthcare information. ACOs will need to capture clinical data not only to report measures but also to drive care improvement initiatives.

How can ACOs create targeted change at the clinic level? Leading organizations are taking a systematic approach—translating each of the 33 quality measures into clinical processes, programs and information systems that drive reporting and improve clinical outcomes.

Case in Point: Operationalizing Measure 12. One of the core strategies of accountable care is to reduce errors and improve patient outcomes through better medication management. ACO Measure 12 supports this goal by requiring organizations to report the percentage of patients who receive timely medication reconciliation after discharge from an inpatient facility. While the measure is straightforward, the underlying problem is complex. Patient hospitalizations usually involve several medication changes, and hospitals do not consistently communicate discharge medications to primary care physicians and other treating providers. Physicians are often unable to determine the rationale of discharge medications and may have a hard time incorporating new drugs and doses into revised care plans. Disjointed medication management—especially for patients with multiple comorbidities—results in post-discharge complications and hospital readmissions.

Considering the full scope of the problem, what does an ACO need to do to operationalize Measure 12? Start with the patient’s needs at discharge and work backwards. The following example illustrates one possible approach:

Clinical behaviors: In most organizations, providers will need to put more emphasis on consistently providing medication reconciliation for recently discharged patients. Nurses may need to adopt new processes for documenting and verifying current medications, and physicians will need to incorporate medication reconciliation into standard practice patterns. All providers will need to document medication reconciliation correctly, which may require additional training.

Clinical data: To perform medication reconciliation in the post-acute clinic, physicians and nurses will need consistent access to discharge medication lists. Create interfaces for pulling discharge medications by drug name, dose, frequency and route from the hospital information system. Building a discharge medication list may involve establishing electronic feeds from hospitalist, specialty consultant and discharge planner notes.

Supporting programs: In addition to processes and information systems that are directly involved in operationalizing Measure 12, an ACO will need to create programs that support new behaviors and drive performance improvement. Organizations might implement one or more of the following:

  • Proactive collaboration: Hospitalists could spearhead an effort to proactively coordinate discharge planning with post-acute physicians.
  • Direct physician contact can simplify medication reconciliation for primary care providers and help prevent drug-related complications.
  • Nurse navigators: New processes are not enough to ensure all patients receive timely medication reconciliation. Someone needs to quarterback the overall system. An ACO could assign nurses to identify patients in post-discharge and schedule appointments with primary care physicians. Create a trigger within the hospital information system to alert a nurse navigator when a patient has been discharged. Use claims data to identify beneficiaries who leak out of the system (e.g., a patient who is hospitalized while vacationing out of state).
  • Patient outreach: Nurse navigators could use contact management software to communicate key information to patients during the post-discharge period. Healthcare-specific contact software exists, but many organizations have simply adapted business contact tools to the healthcare environment. Home health nurses could facilitate medication reconciliation for the most complex patients and work with patients to ensure medication compliance.

The system described above is only one way to operationalize Measure 12. Several effective approaches are possible. The important point is to develop a strategy that aligns clinical operations with the goals of the measure, with a comprehensive system of interventions built on care plans, clinical roles, efficient communication and electronic exchange of information. Implemented appropriately, a comprehensive strategy will help caregivers achieve advanced performance outcomes and higher quality patient care following hospitalization.

Tools and Techniques. Clinical process translation is a huge task. ACOs need to establish new work processes, create new data feeds to populate the clinical disease registry, and develop new support programs for each of the 33 quality measures. Ideally, all new processes will be rolled up into a comprehensive care management program for ACO beneficiaries.

One approach is to develop an Acute-to-Ambulatory Transition Program that coordinates medication reconciliation efforts with other care initiatives. The program could identify patients who have been admitted to an inpatient facility and take steps to address the risks that lead to preventable readmissions. Specific program elements could include better efforts to create and communicate discharge care plans. Contact management tools could be used to communicate with primary care physicians and send education materials and appointment reminders to patients.

How can an ACO manage a patient population across multiple care programs? The most useful tool is the care gap report. Populated from the ACO’s clinical disease registry, care gap reports identify discrepancies between care protocols and the actual care delivered to specific patients. ACOs can use care gap reports to track their performance on both quality measures and the clinical processes that support them. For instance, ACOs need to improve the health of diabetic patients through better hemoglobin A1c control (Measures 22 and 27). Providers could use a care gap report to flag patients who have not had an HbA1c reading in the last three months. Nurse navigators or other program staff could then contact patients to schedule lab work and guide appropriate follow-through.

Care gap reports can tie together several measures to enable more efficient interventions. For example, if a patient has been identified to come in for an HbA1c blood test, the report could also prompt a flu shot (Measure 14), pneumococcal vaccine (Measure 15) and other preventive health services. The system could also be configured so that care gap reports trigger alerts within the ambulatory EMR, prompting physicians and nurses to deliver protocol interventions. As the Shared Savings Program transitions from pure reporting to performance measurement, care gap reports will become a critical tool not only for meeting quality measures but for driving clinical process change and managing costs. Process improvement dovetails with current efforts to operationalize the ACO measures. Both follow an evolution:

  • First, capture the clinical information elements needed to drive the measures.
  • Second, aggregate the data elements to enable analysis.
  • Third, interpret the data to drive improvements in clinical workflow and care coordination.

Clinical process improvement will ultimately be the main driver of ACO performance and profitability. To the extent that ACOs can do a better job of managing care for high-risk and transitional-risk patients, they will dramatically improve clinical and financial outcomes.
Ongoing Performance Gains. A systematic approach to operationalizing the 33 quality measures will help organizations ensure that clinical process workflows support care management goals. Process translation teams should include strong representation from clinical providers and administrative staff, including physicians, nurses and IT technicians. Multidisciplinary collaboration is the key to creating clinical processes that not only enable reporting, but allow an ACO to achieve ongoing performance gains by controlling costs and improving patient outcomes.

Clinical Integration, CI, Physician Alignment

Topics: Accountable Care, ACO, Clinical Integration, Medicare, Clinically Integrated Care, Clinical Process, 33 Quality Measures, Accountable Care Organizations, Clinical Care

9 Tech Building Blocks for a CIO's Accountable Care System

Posted by Matthew Smith on Mar 13, 2013 9:28:00 AM

By Daniel J. Marino, President & CEO, Health Directions

Part 3 of a 3-Part Series

ACO, Clinical Integration, CIOThe CIO’s job is to build an IT infrastructure that delivers core functionalities in a way that supports the hospital’s accountable care strategy with regard to physicians, other provider entities, payers and the market. The key to creating an IT system that delivers on hospital strategy is to understand the different components of an accountable care infrastructure.

Following are the nine IT building blocks of an accountable care system, including critical success factors, strengths and weaknesses of different options, typical selection problems, common misconceptions and implementation best practices. CIOs can configure these building blocks to meet any set of strategic needs and position their hospital to function in the world of accountable care.

1. Standards-Based Information Exchange
Hospital IT departments are currently focusing on technical solutions to exchanging data between hospital and ambulatory systems, including ambulatory EMR and practice management systems, hospital EMR systems and other ancillary hospital systems. For CIOs, the important thing is to understand that the goal is not just to exchange data, but to exchange data in a format so that it can be coordinated and accessed across the care continuum. Without standards-based information exchange, healthcare organizations will continue to be data-rich and information-poor.

A basic question is which standard to adopt—Continuity of Care Record (CCR) or Continuity of Care Document (CCD)? The answer depends in part on the capabilities of your application vendors. It also depends on what kind of information you want to exchange and what you want to do with it. Ultimately, that depends on your organization’s clinical and strategic goals.
The CCR format is built upon a limited number of data fields. The benefit of a CCR file is that data is entirely structured, allowing for full exchange and usability by computer systems. The format is also simpler, allowing for easier set-up with a broad range of provider entities. A CCR-based system is well suited for exchanging basic patient snapshots across a wide range of providers.

The CCD format includes structured data fields and the ability to enter “narrative” information. While CCD is more complex and does not offer fully structured data, it is also better suited to managing the huge amount of information that currently exists on paper. CCD may be the best option for rich information exchange between providers that have ambitious goals for care management.

Existing systems are also a consideration. What exchange platforms are currently in use within your hospital? What is being used by community providers? How will this information be used to support clinically integrated care? The answers to these questions are the foundation for building a true patient longitudinal record.

2. Agnostic Application Strategy
Since the goal is connectivity, an effective accountable care infrastructure will need to be vendor-agnostic. All applications must be able to interface with other systems within the network. From a planning point of view, there are two pitfalls:

  • One danger is presented by IT applications promoted by individual hospital departments or community provider organizations. For example, say the medical oncology department advocates a particular software package for managing infusions. If that system does not interface with other applications such as the pharmacy system or the acute EMR, then interoperability cannot be achieved. The software may be a great infusion management solution, but if it does not support clinical integration around shared data, true coordinated care will be a challenge. The overall need for full data integration takes precedence.
  • The second pitfall is the danger inherent in an enterprise solution. There are several very good integrated solutions available for hospital and ambulatory information systems. However, some of these enterprise systems do not work well with other applications. Connections may be possible, but the preference is staying within the platform. Overall, integrated solutions offer many benefits such as strong core connectivity, and they can make implementation easier. Again, however, if the system prevents full clinical integration and coordinated care management, it will undermine the goal of accountable care. CIOs need to make sure any enterprise solution allows for full connectivity—or negotiate within the vendor agreement that the system will allow for an efficient exchange of information with applications outside the platform.

3. Interoperability
Once information systems have a common language (the exchange standard) and the ability to be heard by each other (agnostic applications), you need to decide what they will say to each other. In concrete terms, decisions need to be made about what structured data will be extracted from which systems, where the data will go and how it will be used.

This will largely involve mapping data from hospital applications into the ambulatory EMR. For example, when a heart failure patient goes to the hospital lab for a BNP test, what will happen to that clinical data element? It must flow into the EMR, but where in the patient record? The answer depends on the network’s accountable care strategy and the needs of physician users. Multiply this example across the full range of possible data elements and it becomes clear that mapping data to achieve interoperability is a huge undertaking.

Many EMR systems come pre-loaded with structured data sets, but hospital IT leaders should be wary of these “out of the box” interoperability solutions. Generic data sets do not work well in most situations, because they generally focus on regulatory requirements and are not individualized to the needs and strategy of the organization.

4. Patient Longitudinal Record
Under traditional paper medical records systems, information sharing involves printing or copying records and physically sending them to another provider. When developing an electronic records system, one pitfall is the temptation to see the EMR as simply a digitized version of the traditional process. Attention is focused on exchanging data between different users. Information sharing is important, but hospital CIOs also need to focus on the underlying goal of EMR, which is to create a longitudinal patient record—one that consolidates and organizes patient health information from every provider into a systematically organized composite record.

A patient longitudinal record is critical to accountable care because it provides physicians with a comprehensive view of the patient’s health history, tests and services. It is seen as an antidote to “episodic care,” in which interventions are based largely on provider specialty with limited knowledge of the patient’s total condition. A longitudinal record enables physicians to manage the patient’s total care experience across acute, ambulatory and long-term care systems, and between multiple provider specialty settings. The driving force is to integrate and harmonize clinical data for providers. For instance, an effective patient record will organize a patient’s name with their complete list of medications from all providers. Beyond that, it will organize brand name medications with generic equivalents, helping to drive efficient clinical decision making at the point of care.

5. Clinical Decision Support Systems
Providing physicians with comprehensive patient information is not the only goal of an EMR system. Healthcare leaders expect EMR to actively drive better care through Clinical Decision Support Systems (CDSS)—automated alerts and reminders that support medical decision making at the point of care. CDSS functions can include alerts for adverse drug interactions, drug allergy reactions and potentially redundant tests; reminders for preventive care services and labs by diagnosis; and automated assistance with prescriptions and dosing.
Most EMR software packages include clinical alert functionalities; but again, using “out of the box” settings and pre-programs is not advisable. Physicians, both employed and community-based, need to lead the process of designing CDSS alerts and reminders based on agreed-upon care protocols—and care protocols must be based on the organization’s specific strategies for achieving accountable care.

For instance, say a hospital/physician network decides to focus on coronary artery disease (CAD) as one of the cornerstones of its accountable care strategy. Successfully managing this condition can reduce overall costs significantly by reducing readmissions and preventing complications like heart failure and arrhythmia. Based on this goal, physicians and other clinical leaders will establish a number of diagnostic and interventional protocols for optimal CAD care. As part of this initiative, the EMR will be configured with supporting CDSS functionalities, such as reminders for periodic blood tests and alerts for test results that fall outside agreed-upon ranges. Alerts could also be configured to flag results and indications that suggest the need for imaging studies or EKGs.

6. Clinical Data Repository
An EMR system is a powerful tool, but it is not the only data management system required for accountable care. This is a source of confusion for many. EMR is a tool for capturing, retrieving and working with patient information at the point of care. It does not allow users to manage the care of a large patient population. To create this capability, an organization needs a clinical data repository (CDR).

A CDR is a database that stores information entered from a variety of provider systems. The database includes structured data elements and standardized data sets for coordinating de-identified patient information, and it offers analytic capabilities that allow clinical data reporting. CDRs enable two processes that are critical to allowing an organization to function as an accountable care provider:

  • First, the CDR creates an infrastructure for joint clinical decision making. Physicians and other clinical leaders can use CDR reports to identify problems with clinical processes and outcomes, develop solutions and track improvement. A powerful CDR will allow clinicians to monitor and improve clinical performance by disease, age group, risk factors, clinical intervention and many other parameters. It also allows hospital and clinical care leaders to help individual providers identify and adopt better clinical practices.
  • Second, a CDR allows an organization to report information required under accountable care payment systems. The structured database is the means for capturing and validating clinical performance and getting paid for attaining performance goals. This will become especially important for organizations that enter into full risk contracts with payers.

7. Personal Health Record Integration
Patient Health Record (PHR) technology is not as well developed as EMRs, and there are a lot of questions about how patients and provider organizations will use it. However, planning for a PHR system cannot be pushed off to the indefinite future. Medicare ACO regulations specify that patients must have electronic links to their health information, and expectations for patient connectivity will increase. Even under less stringent commercial accountable care programs, organizations recognize a strong need to engage patients in their care and use electronic technology to involve individuals in disease management efforts.

No matter what the current state of an organization’s accountable care program, CIOs need to start creating plans for incorporating a PHR system into an accountable care infrastructure. Technically, the issue is establishing the interfaces to get PHR data feeding into ambulatory EMR, acute EMR and patient registration systems. More important, the organization needs to make decisions about what information will be captured in a PHR and how it will be used.
Again, organizational strategy is the driver. Begin by building the PHR around the organization’s core accountable care projects. For example, if the organization is beginning with a clinical integration effort around hypertension, the first step might be to allow patients to log medication use and home blood pressure readings within the PHR and receive periodic reminders about diet, exercise and stress management.

8. Business Intelligence Capabilities
A key mechanism of the accountable care model is holding providers financially responsible for spending, at least within certain parameters. Given that fact, clinical information systems and traditional business information systems are not enough for supporting accountable care. Organizations need to develop robust business intelligence capabilities that allow leaders to manage the financial side of care proactively.

A business intelligence system capable of supporting accountable care will include a data warehouse system with versatile analytical tools. The system will need to incorporate data from hospital financial information systems and physician practice management systems and fold in data from the CDR.

The functional objective of the system is to allow multi-dimensional reporting that encompasses physician and hospital services, patient clinical data, and patient claims data. The immediate goal is to be able to tie clinical outcomes to claims data to identify the cost of care for various diagnoses. The ultimate goal is to use the business intelligence system to identify opportunities to reduce waste, reduce spending and improve operational efficiency and leverage those improvements financially under accountable care contracts.

9. Health Information Exchange
Many healthcare leaders think of a Health Information Exchange (HIE) as an interface engine. This is only partially true. An interface engine transmits data points from system A to system B (for example, diagnostic results from the lab system to the physician EMR). An HIE allows for much more robust connectivity, linking all systems within a community, including internal hospital systems and independent provider systems. An HIE captures outcomes data and organizes patient information across all participating entities. More importantly, it allows information to be exchanged in a federated or “open access” model in which organizations can share or protect information selectively.

How should the IT department plan and design an HIE infrastructure? Once more, CIOs need to make these decisions in the context of organizational strategy. A hospital that intends to lead an accountable care initiative should consider developing its own private HIE so it can determine what data is collected and shared. A community hospital that simply wants to keep up with the industry should examine the possibility of connecting with one of the many state or regional HIE initiatives being developed. Another issue is market strategy. Decisions about an HIE should be aligned with the organization’s service area schema, physician integration strategy and any plans for market expansion.

Staying Focused
In working with all these building blocks, the main point is to stay focused on the basic goals. Look at interface design in light of the need to create information that will help the organization manage and control costs and improve quality. Make system selection choices based on the need to provide comprehensive patient information at the point of care, creating a true patient longitudinal record. Most of all, make sure all decisions about specific applications and overall interoperability are driven by a physician-hospital leadership governance body that has ownership of the hospital’s total accountable care strategy.

Ultimately, the definition of a high-performing IT infrastructure is one that helps the hospital achieve its goals for collaborating with specific provider organizations, improving outcomes for specific patient populations and positioning the organization for success within the ever-changing world of accountable care.

Electronic Health Records EHR Assessment

Topics: ACO, Clinical Integration, CIO, HIT, Health IT, Accountable Care Organizations, Clinical Care, Hospital Technology, IT, Strategy, Strategic Health Care

Demystifying Clinical Integration

Posted by Matthew Smith on Mar 4, 2013 11:31:00 PM

Clinical IntegrationThe American health care industry is under tremendous pressure to lower medical costs and improve quality.

The concept of reducing cost by improving quality is at the heart of the lean production principles that have revolutionized many other industries, and by standardizing processes and establishing shared baselines to reduce variation in care delivery, Intermountain Healthcare in Utah and Idaho has become one of the most successful systems in the country at improving quality and reducing costs. For example, by implementing a protocol designed to reduce elective labor inductions, the system significantly reduced unplanned surgical deliveries and neonatal intensive care admissions. System administrators estimate this one protocol reduces health care costs in Utah by $50 million a year. Today, Intermountain manages 60 clinical processes in this manner, making up almost 80 percent of the system’s clinical activities.

Keys to Success

There are several model systems around the country exhibiting positive results in quality improvement and cost reduction, but most have been pursuing these goals for several years. A health system needs a solid infrastructure of information technology, physician leadership, administrative governance, and quality measurement to support such coordination across inpatient and outpatient care delivery. To even begin establishing protocols to achieve best practices, measuring results, making improvements to the protocols, and reducing process variation, participating physicians must be clinically integrated with their regional health system.

Clinical integration has been around much longer than this latest round of health system reform, but because of its relation to accountable care organizations, the concept has become newly fashionable among health policy wonks. To understand what’s meant by the phrase these days, you have to distinguish between clinical integration as a legal construct and clinical integration as a practical concept to improve the quality of patient care.

Under most circumstances, a group of independent physicians can’t band together and negotiate jointly with health plans to set rates for services without violating antitrust law, but the Department of Justice and the Federal Trade Commission have held that a group of independent physicians that are either clinically or financially integrated can negotiate contracts as an organization in a so-called antitrust safety zone. Neither the DOJ nor the FTC wish to dictate how to achieve clinical integration, but a number of statements, rulings, and speeches serve to define the necessary components. Here’s what the agencies published in the most recentStatement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program:

“Clinical integration can be evidenced by the joint venture implementing an active and ongoing program to evaluate and modify practice patterns by the venture’s providers and to create a high degree of interdependence and cooperation among the providers to control costs and ensure quality.”

In a fee-for-service payment environment, this legal safety zone for clinical integration programs is a powerful tool for independent physician associations, physician-hospital organizations, and accountable care organizations to negotiate contracts. Apart from the legal considerations however, the practical application of clinical integration is a key component of improved efficiency and measurable quality improvement in care delivery.

Houston is home to one of Texas’ most advanced integrated health care systems, Memorial Hermann. Christopher Lloyd is CEO of the Memorial Hermann Physician Network, MHMD, a 3,900-physician IPA affiliated with Memorial Hermann. He says the network launched its clinical integration—or CI—program about five years ago, and since then, the clinically integrated subset of MHMD has grown to about 2,600 physicians across a broad spectrum of specialties.

Evidence-Based Medicine

Physicians in the CI program sign an agreement to practice evidence-based medicine as defined by standards set by their peers, to share their clinical data transparently, and to use standardized clinical protocols, order sets, and processes. “When they sign that agreement with us, they’ve agreed to participate in the processes and mechanisms that allow them to have an impact on those processes, and on the standardization of treatment and the management of costs and quality,” Lloyd says.

When compared to their peers and to national benchmarks adjusted for severity, Lloyd says the CI doctors at MHMD perform remarkably well. The average length of stay for their hospital patients is 30 percent lower than their peers. He says complications occurring as a result of inpatient hospitalization for the CI group are 15 percent lower than their peers, their 30-day readmission rates are 4 percent lower, and the average charges for their patients are 33 percent lower.

The physicians establish and adjust the protocols and order sets themselves by participating in specialty-specific clinical program councils. “Really, what’s interesting about this model is that it is primarily comprised of independent physicians, and these independent physicians are functioning in leadership levels collaborating around care management principles when otherwise, they wouldn’t have to.

“What we have found is that when we arm them with data and arm them with information, and provide them a forum to then focus and start managing across the clinical enterprise, the standards and protocols and order sets then become best practice, because they’re doing research about best practices across the country.”

“We’re building an entity that will have the infrastructure to excel at coordinated, high-quality, low-cost care while accepting multiple forms of value-based payments,” says Greg Sheff, M.D., president and chief medical officer of Seton Health Alliance. A family physician and TAFP member, Sheff also serves as medical director of care management and clinical integration for ARC, a multispecialty group of about 300 physicians.

“Obviously acute care and hospital care are incredibly important parts of the health care experience, so the more we integrate with that, the better for our patients,” Sheff says. “And it also brings capital and resources that allow us to build the IT and care management infrastructure to really look at populations in addition to individuals.”

Enter Health Directions

To help create the new ACO, the alliance has enlisted the services of Health Directions, a Chicago-based health system consulting firm. Daniel Marino, president and CEO of Health Directions, says his favorite definition of clinical integration comes from the American Hospital Association: “Clinical integration facilitates the coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patient-focused.”

Marino says to successfully implement a clinical integration program, the physicians involved have to lead the transition. “The cultural change is probably one of the biggest obstacles. You’ve got to get community physicians aligned with the hospital, and historically the interests and the objectives have always been a little bit different.” Collaboration and shared accountability across the entire organization is critical, as is the ability to collect, measure, and analyze clinical data. “At the end of the day, you’re doing this to create some value collectively for physicians and the hospital.”

Creating a clinically-integrated IPA, physician-hospital organization, or ACO are just a few ways communities can organize care to be more efficient and improve quality, and the rate of transition to value-based care as well as the various forms that may take will be different in each community. Clinical integration, as Sheff puts it, is one of the levers you can pull when you want to manage health. He says the imperative for family physicians today is not how to prepare for clinical integration, but rather how to get ready for change.

For physicians considering clinical integration for contracting purposes, Sheff says they can expect a positive return on their investment if done properly. “Especially for a small group, if they have the opportunity to join a clinically-integrated entity, they could see improvement in their reimbursement rates while having access to resources that help them improve the quality and efficiency of their patients’ care.”

A Storm is Coming

When Marino speaks to physician groups, he tells them a storm is coming. Many metropolitan communities feel the pressure now, while in other regions, major changes to the way care is delivered and paid for may be years away.

“Physicians really don’t have to do anything,” he says, “but if they don’t do anything, they have to know that there’s going to be continued pressure to reduce their fee schedules, lower reimbursement from the payers, and most likely reduced compensation. If they want to position themselves for continued growth, position themselves to try to create value so they can negotiate higher rates, then they have to begin to make some change.”

Clinical Integration, 4-Pillar Approach

Topics: Accountable Care, ACO, Clinical Integration, Clinically Integrated Care, Accountable Care Organizations, Clinical Care

Family Physicians & Clinical Integration: The Case for Involvement

Posted by Matthew Smith on Mar 3, 2013 9:36:00 PM

Clinical integration, clinically integrated careWhat is your reaction to the concept of clinical integration? If you are like most physicians I talk to, you are interested in the idea but wary of the many uncertainties that surround it. You may also have some reservations about getting involved with the local hospital. If you become clinically integrated, will you be able to maintain control of your own practice?

One thing is clear: Doing nothing is not an option. Unsustainable health care cost trends are creating pressure that is simply not going away. All payers are pushing to reduce costs, and there is broad and deep agreement that greater coordination of care is the solution. Physicians who stick to the clinical models developed under fee-for-service reimbursement are going to suffer from steady fee schedule reductions.

The good news is that family physicians who are interested in exploring collaborative care models have several options. One possibility is the patient-centered medical home. Developing a medical home model in your practice will allow you to put greater focus on coordinating patient care. Improving patient management will enable you to negotiate value-based reimbursement with payers. One disadvantage of the medical home model is that it limits the scope of care coordination to the factors that are under your control as a primary care provider.

The other option is clinical integration with a hospital. On the patient care side, clinical integration offers unprecedented opportunities to coordinate care as patients move between primary care, specialty medicine, hospital, and long-term care settings. On the contracting side, clinical integration opens up new possibilities for securing better reimbursement for better patient quality outcomes. Given the cost control pressures that are driving the industry today, clinical integration may offer family physicians the best chance of surviving financially in the years ahead.

Of course, the big question for physicians is where does this leave practice autonomy? One answer is to look at clinical integration from the point of view of leadership.

Who will be in charge of hospital-physician clinical collaborations? Based on discussions with hospital CEOs from across the country, I can tell you that without exception hospitals are looking to physicians for strong leadership on clinical integration programs. There is widespread recognition that the only stakeholders who can effectively guide coordinated care are physicians. Physicians are being asked to take part in decision-making at every level, lead on the development of quality metrics, and help guide implementation at the unit level.

And practice autonomy can remain strong. Hospitals are acquiring physician practices in many markets as part of their integration strategy, but clinical integration can develop outside of hospital employment. Information technology and shared governance structures are carving out a viable niche for physicians who want to collaborate with hospitals while still remaining independent.

What many physicians find most exciting is that they see clinical integration as an opportunity to practice medicine as they were trained to. Under fee-for-service reimbursement, physicians are underpaid for the cognitive work that defines the best medical practice—the time- and cost-intensive work required to diagnose and manage difficult cases and maintain patient wellness. Clinical integration gives physicians the opportunity to focus their skills on outcomes. Physicians will be able to work at both the population level and the patient level to prevent the complications of chronic disease, keep patients out of the hospital, and optimize patient health.

Interested in moving forward? To prepare your practice for clinical integration, the key is to focus on technology. If you have not already done so, make the transition to an electronic medical record and work to meet the government’s meaningful use requirements. Then begin tracking clinical outcomes on chronic diseases within your practice. Diabetes and coronary artery disease are common starting points.

As you begin to get technology and quality tracking in order, you can also explore opportunities to collaborate. In most communities, clinical integration initiatives are still in the early planning phase. Structures, goals, and incentives are still uncertain—but that’s good. Family physicians who get involved now have a real opportunity to shape how clinical integration will develop in their community for years to come.

Clinical Integration, 4-Pillar Approach

Topics: Clinical Integration, Primary Care Physicians, Family Physicians, Clinical Care

New Study Says Primary Care Docs Meet Diabetics' Needs

Posted by Matthew Smith on Dec 13, 2012 3:36:00 PM

Diabetic ManagementAccording to a new study by Brigham and Women's Hospital, primary care doctors provide superior care for patients with diabetes and note that electronic health records provide a solution to bridging the gaps observed in their research.

"We found that primary care physicians provide better care to diabetes patients when compared to other providers in a primary care setting because they were more likely to alter medications and consistently provide lifestyle counseling," study senior author Dr. Alexander Turchin, a physician and researcher in the division of endocrinology at Brigham and Women's Hospital, said in a hospital news release.

The study assessed primary care received by more than 27,000 diabetes patients at two academic medical centers. In total, the patients had nearly 585,000 primary care appointments over an average of five years and five months, and 83 percent of those visits were with a primary care doctor. The rest of the visits were with a covering physician, nurse practitioner or physician assistant.

Overall, medication intensification (either having a new medication prescribed or the dose of a current medication increased) occurred in 10 percent of the visits, and lifestyle counseling occurred in 40 percent of the visits.

But the researchers found that the likelihood of medication intensification and lifestyle counseling were much higher when patients saw a primary care doctor than when they saw another health care provider, according to the study published in the Dec. 10 issue of the journal Diabetes Care.

"Access to care is important and covering physicians and other providers play an important role in increasing access, especially in patients with acute complaints," Turchin said. "With growing focus on a team-based approach to practicing medicine, this finding should help guide the development of new models of primary care, especially in the care of diabetes patients."

To help bridge the gaps observed in the study, the researchers recommend better documentation and communication of the treatment plan through electronic medical records to other care providers.

Click the button, below, to learn how Health Directions helps primary care physician practices:

  • Achieve CMS EHR “meaningful use” or NCQA PCMH recognition
  • Leverage “reportable” quality of care and outcomes for better reimbursement
  • Participate in pilot programs with local payers
  • Partner with local health systems to create electronic linkages
  • Increase patient satisfaction
  • Improve practice profitability
  • Strategically position themselves for the future 

 

Topics: EHR, EMR, Electronic Health Records, Electronic Medical Records, Clinical Integration, Health IT, Clinically Integrated Care, Clinical Care, Coordinated Care

6 Population Types Benefiting from Clinical Integration

Posted by Matthew Smith on Dec 12, 2012 10:30:00 AM

Clinical IntegrationHospitals and physicians face mounting pressures to change their care delivery models moving from encounter-based care to population health management. This results in challenges such as:

  • Patients experiencing fragmented and uncoordinated care between the hospital, post-acute and ambulatory setting
  • Physicians unable to access the most appropriate clinical information at the point of care resulting in misdiagnosis, redundant care delivery and high costs
  • Hospital and providers struggling with managing patients with chronic diseases and complex illnesses—resulting in lower quality patient outcomes, higher readmission rates and higher costs
  • Hospitals and physicians feeling pressures from payers to accept lower reimbursement while focusing on improve patient care outcomes

A fully implemented Clinical Integration program benefits everyone in the community. Here is a look at who stands to benefit from clinically integrated care, and how each group will benefit.

Patients

  • Improved safety

  • Improved quality of health care

  • Better access to the latest proven techniques and treatments

  • Streamlined interactions with health care system—less waiting and duplication

  • Fully informed physicians and medical staff

Physicians

  • Ability to spend more time with patients, less time with paperwork

  • Access to complete patient information

  • Ability to deliver higher quality care

  • Ability to monitor patient compliance

  • Ability to sell combined services of network to payors, making independent practice more viable, especially for small practices

Hospitals

  • Higher degree of effective collaboration

  • Improved clinical quality and patient safety

  • Base of independent physicians aligned with hospital

  • Ability to manage costs

  • Differentiation in the market as high quality provider

Insurers

  • Higher subscriber satisfaction

  • Cost efficiencies and savings

  • Higher quality health care for subscribers

  • Easy access to objective utilization data

Employers

  • Containment of health care costs

  • Healthier employees

Community

  • Ability to maintain independent physician practices

  • Better health care

  • Ability to recruit medical talent to area

Topics: Clinical Integration, Clinically Integrated Care, Clinical Care, Population Health Management

Technology Spending and Accountable Care

Posted by Matthew Smith on Dec 9, 2012 9:42:00 AM

Clinical care technologyOne of the factors driving growth in healthcare IT is the push for accountable care and clinically integrated care. Hospitals are making significant investments in technology to support clinical information exchanges, clinical integration and performance-based reimbursement models.

The challenge for hospital CEOs is how to gauge return on investment (ROI). Technology budget proposals can typically be evaluated in terms of efficiency gains, cost reductions and service line enhancements. For some IT projects, ROI can justify upfront costs. Unfortunately, accountable care is different. New clinical and reimbursement models are not yet mature enough to support profitability. Accountable care technology support systems are an investment in a long-term strategy, not near-term gains.

Still, IT spending needs to be a sustainable investment, with a realistic financial rationale and manageable current costs. How can hospital CEOs guide a responsible approach to building the IT infrastructure for an accountable care organization (ACO)? The key is focusing on core goals, strategies to improve care and technical solutions required for success.

Understand the Target

The twin goals of accountable care are to reduce costs and improve patient clinical outcomes. The emphasis is on the preventable conditions and chronic diseases that consume up to 80 percent of all healthcare spending. In other words, accountable care is all about managing populations, not just individual patients.

How does this differ from the old managed care model? As practiced in the 1990s, managed care was primarily a contracting process. The objective was to direct patients to the lowest-cost provider. Incentives for disease management existed, but they were several steps removed from desired outcomes. Accountable care, in contrast, is a clinical process. Its objective is to direct patients to the lowest appropriate point of care. Incentives are tied directly to an organization’s ability to guide patients through the least expensive interventions while achieving the best possible clinical results.

What is the implication for IT planning? Hospitals have to focus on building a technology infrastructure that enables proactive population management and intervention-based programs. Knowing information about a patient after the fact is not enough. ACOs need tools that enable them to know which patients are most at risk for high-cost services and expensive readmissions, and provide interventions that help guide patients toward better outcomes.

Build for Two Key Functions

Drilling down to the level of operations, proactive population management calls for two basic types of technology— those that enable predictive modeling and help providers make effective decisions at the point of care. 

The overriding need at the point of care is a patient longitudinal record, a medical record that rolls up patient clinical and demographic data from information systems across the continuum of care. A true patient longitudinal record enables physicians and other caregivers to provide coordinated care, eliminate redundant services, improve test result follow-up, etc. Key systems include an EHR and a health information exchange (HIE). The HIE must exchange data via continuity of care documents that populate provider EHRs at the point of care, integrating patient information seamlessly into clinical workflows. To safeguard data, information security is managed in the HIE through secure Internet protocols and security agreements between participants.

The technology and systems supporting predictive modeling are more complex. The goal is to develop the ability to extract data from a variety of information systems, organize the data and analyze it to produce valuable clinical information. One required system is a clinical disease repository to structure and store information. Organizations will also need to acquire business intelligence systems capable of tying claims-based information to clinical data to identify care gaps and the cost of care. As a coordinated infrastructure, these systems will enable an organization to identify effective population- based interventions and deliver them at the point of care. Leading organizations are also developing ways to reinforce clinical integration through patient-facing systems, including patient portals, homebased tracking tools and personal health records.

Adjust for the Environment

Of course, effective technology design goes beyond systems and functionalities. Taking a realistic look at the environment is the key to guiding the development of practical IT solutions for accountable care. First, examine your assumptions about system integration. Some ACO plans call for getting all providers on a common technology platform. This is unrealistic. In most communities, provider organizations have invested significant time and money in a wide variety of information systems. Migrating everyone to a common platform is simply not going to happen. Instead, hospital leaders need to focus on technology solutions that allow different provider systems to interface and exchange information. One option is creating a shared system. Hospital systems SwedishAmerican Health System, Rockford, Ill., and FHN, Freeport, Ill., collaborated to create TriRivers Health Partners. TriRivers is developing an infrastructure for a clinical information exchange using a “private cloud” model. This hosted IT service is saving money and enabling the two organizations to exchange information with each other as well as other independent providers in the community. The TriRivers solution will offer a true exchange of healthcare data, while allowing providers to remain and operate within their respective EHR applications.

Attack the Variables

Hospital CEOs can contribute the most to the technology planning process by helping staff maintain focus on the non-IT variables that will make or break accountable care. One key variable is the challenge of using data effectively. Measuring and tracking data are key competencies of accountable care. Yet gathering good data is not enough. Organizations also need to be able to turn that data into action. Many hospitals that are committed to tracking performance data find it a challenge to turn data into performance.

For an ACO to succeed, an organization must be able to understand the data and use it to plan and execute concrete interventions. Another key variable in accountable care is physician alignment. Physicians stand at the center of any effort to manage population health, as they are responsible for devising quality measures, guiding disease management initiatives and implementing interventions and protocols. Many of the specialists who are most important in cost-control efforts, however, have little desire to partner with the hospital on accountable care. Other physicians are very motivated to align with the hospital, but the challenge with these providers is figuring out how to divide a shrinking healthcare dollar. In addition, even after incentives are aligned, hospitals and their physician partners will still need to overcome an array of obstacles—for example, helping physicians achieve optimal use of their EHR to support clinical integration. Given these challenges, hospital CEOs who are leading an accountable care initiative will need to prioritize efforts to work with and support employed and communitybased physicians.

Finding a Sustainable Path

Building the IT infrastructure for accountable care is a huge endeavor that could be very expensive. The CEO’s job right now is to help IT, administrative and clinical leaders find a sustainable path. Keeping your organization focused on key goals and realities will help ensure that ACO technology spending is a sustainable investment in an effective, long-term strategy.

 

Topics: Accountable Care, ACO, Clinical Integration, CIO, HIT, HealthIT, Clinically Integrated Care, Accountable Care Organizations, Clinical Care

Infographic: 10 Benefits of Health IT

Posted by Matthew Smith on Nov 20, 2012 9:08:00 AM

The infographic below highlights 10 examples of how health IT can benefit physicians, patients and providers. Health IT can assist in patients by enabling informed decision making and enhanced quality of care. Health IT enables remote consultations, whether urgent or diagnostic, more efficient and cost-effective delivery of care and helps reduce the risk of negative drug interactions or poor response to a course of treatment when analyzing patient data.

Given the rising cost of healthcare, health IT provides healthcare staff, clinicians, and administrator’s access to data they need to make better decisions for the organization as a whole.

Infographic via ihealthtran.com 

Topics: EHR, Clinical Integration, HIT, Health IT, Clinically Integrated Care, Clinical Care

10 Benefits of Clinically Integrated Care

Posted by Matthew Smith on Oct 16, 2012 3:55:00 PM

Clinical IntegrationIn today's healthcare landscape, there are a wide-range of approaches and strategies employed to achieve successful clinical integration (“CI”). Regardless of the strategy, when designed and implemented correctly, CI offers tremendous potentials for efficiencies and improvements in healthcare quality and patient satisfaction.

Here are 10 identified benefits of CI to consider when exploring your CI options and feasability:

  1. Increased Collaboration: The use of care teams to implement a CI program addresses gaps in the care continuum while reducing ineffective or unneeded process steps. This approach allows hospitals and healthcare providers to learn to operate as a team to better align, or realign, their efforts to improve quality, patient safety, and patient and family satisfaction.
  2. Improved Efficiency: CI eliminates healthcare waste and redundancy, making it possible for hospital systems to provide patients focused seamless systems of care across and between healthcare providers.
  3. Integrated Systems: CI programs provide hospital systems with many more monitoring and enforcement tools than through a typical medical staff organization, including the payment of financial incentives for physicians who actively participate in the program and penalties for those who do not.
  4. Payer Partnerships: As CI improves the quality of patient care and clinical processes and reduces costs, hospitals are able to achieve market differentiation. This type of differentiation is attractive to health plans and can serve as the catalyst for payer partnerships.
  5. Improved Care Management: Organizations that are successfully clinically integrated benefit from improved care management. Patients who see multiple doctors are well aware of the fragmented and redundant services and care they receive. Case management serves as the foundation to accomplish coordination of care across traditional health settings. Its goal is to achieve the best clinical and cost outcomes for both patient and provider and is most successful when case managers are able to work within and outside organized health systems.
  6. Integrated Continuum of Care: At the center of CI is teamwork among healthcare providers working to ensure patients get the right care at the right time in the right setting. CI care management teams collaborate with adult day care, independent living, assisted living, and skilled nursing facility partners. Together, with infrastructure focused on supporting caregivers and patients to efficiently assess, document, communicate, and meet patient needs enables hospital systems and healthcare networks to achieve this core objective.
  7. Clinical Data Systems: An integrated technology (“IT”) platform that supports continuity of care and enables access to medical history and critical patient data for all stakeholders is imperative in CI, easing communications across the care continuum and providing information that measures service, performance, quality, and outcomes on an individual provider and network-wide basis.
  8. Patient-centered Communication: In many networks, communication skills training is provided to physicians and healthcare providers with the goal of establishing clear channels of communication as a vital part of the CI program. The Joint Commission has cited communication breakdown as the single greatest contributing factor to sentinel events and delays in care in U.S. hospitals. The CI emphasis on timely and clear communication is key to influencing patient behavior, resulting in cost/quality benefits.
  9. Improved Pharmaceutical Management: Most medication errors are not caused by individual carelessness, but rather by faulty processes that lead people to make mistakes or fail to prevent the mistakes. CI improves pharmaceutical management allowing hospitals to identify gaps in the medication management process and allow them to take actions to help make patients safer.
  10. Improved Health of the Community: CI emphasizes wellness initiatives such as outreach programs and classes to empower the patient with tools, knowledge, and practical solutions to participate actively in their care, ultimately leading to a healthier population. Extensive research in the past three decades indicates that receiving wellness and prevention advice and care from trusted local hospitals and physicians resonates with individuals.

Topics: Clinical Integration, Clinically Integrated Care, Joint Commission, PCMH, Patient Centered Medical Home, Clinical Care

Subscribe to Email Updates

Value Model, Health Analytics

Posts by Topic

Follow Me