HIT and Accountable Care

Today’s Objectives

1. Establish accountable care as foundational for reforming

health care

2. Establish HIT as foundational for accountable care

3. Introduce the consensus developed publicly available

ACO/HIT Framework www.cchit.org/hitframework

4. Suggest implementation approaches

5. Discuss the ACO Workgroup’s draft recommendations to

the HIT Policy Council regarding how HHS can better

support the accountable care environment

Historical Silos: Fragmented Care

Payer: Focus on Members

Costs, and Measures • Contracts with multiple providers

• Benefits vary per member

• Available networks per member

• Claims (what was paid for)

• Diagnoses (on claims)

• Clinical data extracted for quality

measurement purposes (HEDIS) for

NCQA, PQRI, etc.)

• Emphasis on measurement

Providers: Focused on the

Patient and Internal Care

Workflows • Reimbursed by multiple payers under

multiple contractual arrangements

• Cares for multiple patients with multiple

benefit structures/networks

• Cares for patients who see multiple

other providers

• Has information on care generated at

point of care only

Community Based Care:

Focused on Individual Needs •Outcomes and goals

•End of life wishes, living wills, etc.

•Cultural preferences

•Health risks

•Public Health programs

•Patient monitored data

•Pastoral, social, familial caregiver supports

•Independent of payer or provider

The Goal of Health Reform

Patient

Focused

Health &

Care

Providers Payers

Community

based care

Basic Concepts: Patient Focused Care

• Emphasis on preventive as well as acute care

• Preventive care provided by teams

• Patients included in the teams

• Clinicians practice at top of their licenses

• HIT must be able to support diverse information

sharing across multiple constituencies

• Data management/analysis foundational

• Attention to social determinants of health

• Focus on outcomes

Getting There

• Changing Roles and

Responsibilities

• Value based vs Volume Based

Payment

• Instantaneous availability of

multiple types of Information

Changing Roles and Responsibilities

The Clinician of Record (legal responsibility)

• Usually a primary care physician/clinician

• Leads a primary care team that conducts follow up, monitoring, and supports preventive care in and out of office

• Organizes and participates in a multi-specialty team if appropriate with patient

The Specialist

• Provides counsel and services as appropriate for care

• Agrees to participate in patients’ team of care

The Organization

• Provides data management and analytical services

• Provides access to needed clinical information (HIE, links, etc.)

• Provides access to needed administrative information (networks, benefits, ADT feeds, etc.)

• Contracts with aligned providers across the continuum of care

Why Focus on HIT for ACOs?

• Changing reimbursement policies: growing accountability

for cost, quality, and patient focused care

– Federal ACO/MSS rule

– Commercial insurers offering multiple types of ACO models

– Some states mandating accountable care from Medicaid

providers

– Over 500 providers groups in some form of financial risk

arrangement

• ACO payment different from HMO capitation of the 1990s

– Emphasis on quality of care as well as patient engagement

– No designated “gatekeepers” -- patients seek care where they

wish

– Care beyond the walls of the accountable provider(s)

• Information needed to support these and changing roles

Technology takes

you beyond

classic acute

clinical care

towards improved

health outcomes

• http://www.countyhealthrankings.org/our-approach

What is the ACO/HIT Framework

• Consensus driven, publically available set of

processes, functions, and HIT capabilities to

support transitions to and through the ACO

environment

• “Glide Path” for providers taking on greater

financial risk

• Tool to assess readiness for assuming risk for

costs, quality, and patient loyalty

• Discussion platform within an institution, among

institutions, for public policy

The Framework Part 1: Summary

• Represents a provider orientation -- how care

delivery functions at the organizational level

• Grounded in goals and objectives of care delivery

• Process oriented in the accountable care delivery

environment with necessary functions outlined for

each process

• Recognizes the importance of partnering with

payers, other providers, community based

organizations, and patients in achieving the goals

and objectives accountable care.

Important Consideration

• Emphasis on Primary HIT requirements

common to all organizations in the accountable

care arena and to all processes – Sharing of health information – among providers internal and

external to organization as well as with patients and their

designated caregivers

– Data integration from multiple sources -- clinical, operational,

financial and patient derived

– Specific patient safety features

– Strong privacy and security protections

• Can be implemented in multiple ways

• Can be implemented by different partners

The Framework Part 2: HIT Capabilities

• Each process and its functions are defined in

detail

• HIT capabilities optimally supporting each of the

64 discrete functions are outlined

• Patient safety features are bolded

• MU 2014 criteria are starred

Care

Coordination

Care Coordination involves two different but related aspects of

patient care. One provides information to the clinician who must be

able to access from and provide relevant clinical data to multiple

sources in order to determine and provide for appropriate next steps

in diagnosis or treatment. The other is to assure that patients are in

the appropriate setting as they transition among multiple levels of

care. Both are important for providing high quality care as well as

mitigating excess, both must incorporate patient needs and

preferences, and both are highly dependent on the ability to quickly

and easily send and query health information on a given patient to

and from multiple electronic sources.

Framework Goal: Help Develop your own

ACO/HIT Glide Path aligned with your Goals Focus Current Situation Transitioning

Environment

Transformed Future

Clinical Culture Physician centric,

individualistic,

authoritative

Primary care based

teams, may include

patient and designees

True collaboration with

all providers, patients

and designees

Cost Efficiency Cost measurement

based on silos of

payer claims

Care coordination and

care management

processes

Strong business

analytics, contracts and

improved clinical

processes

Reimbursement Incentive Mostly FFS, moving

into upside financial

risk

Significant up and

downside risk

Most patients under

global payment

arrangements

Patient Involvement Patient satisfaction

surveys (to the

patient)

Patient outreach and

follow up (for the

patient)

Patient as partners (with

the patient)

Quality of Care Reporting on a

myriad of measures

to a myriad of

entities

Manage specific cohorts

to individual goals

CQI based care process

reengineering

Major Challenges

Many provider groups simply not ready – Insufficient capital

– Governance

– Inadequate HIT systems

– No opportunity for a PCMH base

– Lack of BH integration

– Not enough patients in risk contract

Payers not aligned – Different contracting arrangements

– Different performance metrics and contracting arrangements

– Different attribution algorithms

– Different types of partnerships

Major Challenges

No access to available administrative data – Full set of claims (total costs of care, financial management)

– ADT feeds

– Social determinants of health

– Real time Eligibility and Benefit information

Inability to exchange clinical data and information – Within ACO environment

– External to ACO environment

– Telehealth

– Remote monitoring devices

• Decrease total costs of care: hospital

admissions, readmissions, and ER visits

• Improve your quality metrics: focus on specified

patient cohorts

• Improve patient satisfaction measures: engage

your cohort patients as much as possible, focus

on outcomes

Initiate HIT Supported, Patient Based

Population Health Management:

aka Cohort Management

Getting Started: Low Hanging Fruit

Critical Components of Cohort

Management

1. ID patients and cohort(s) (data and analytics)

• Predictive modeling for high cost patients (need all claims, patient

supplied, and clinical data)

• ID by procedures, dx, gender, age, meds, etc.

2. Prioritize your cohorts (data and analytics)

• Opportunities to decrease cost

• Opportunities to improve quality metrics

• The Scope/Resources/Time Triangle

• ROI analyses

Critical Components

3. CDS – HIT system support

• non intrusive, usable for clinician AND patient

• appropriate to cohort

• reliable, valid, accurate

4. Ability to monitor and flag events and results – HIT

system support

• Access to ADT feeds

• Specified milestones and goals

• Trending capabilities

• Applicable to all patients in a specified cohort

Critical Components

5. Patient Engagement – multiple HIT approaches

• Culturally appropriate information and educational materials

• Secure messaging, texting, etc.

• Capture data from remote monitoring devices

• Patient/caregiver access to own data and records

• Participation in team assessments and planning

6. Preferred Provider Engagement-referral network

• Include community based services

• Include all relevant specialties on team (BH)

Critical Components

7. Shared Careplans -- HIT system support • Accessible by all providers as well as patient/caregiver,

including hospital staff as needed

• Includes patient specified goals and objectives

• Includes information on HC proxy and/or MOLST

8. Appropriate Interventions – HIT system support • CPOE, ROE

• Access to up to date clinical reviews

• Incorporation of patient preferences

• Scheduling on behalf of the patient

Critical Components

9. Follow up – HIT System Support • Record all results

• Notify clinician if appointment, test, procedure, medication not obtained or kept

• Update careplans and monitoring applications

• Communicate with patient

10. Monitor the Cohort – Data Analytics • Quality indicator goals being met

• Savings accrued

• Patient satisfaction

• Program costs

Attend to your Drivers

• Payment reform at all levels (clinicians)

• Robust Health Information Exchange

• Data access (claims, clinical, administrative,

patient reported, data on social determinants),

integration, analysis (monitor, predict, plan)

• Programs and processes for patient

management outside of the traditional delivery

system

• Culture change -- at all levels

Culture Change: Early Goals

Ambulatory Care

Minimize Administrative Burden

Establish Patient Centered Medical Homes

Integrate BH (MH and SA) and Primary Care

Hospital:

Minimize administrative burden

Establish multi-disciplinary care teams

Extend discharge planning through next

encounter

Five Components of Culture Change

• Simplify -- minimize clinicians’ administrative burden, do not add

to it; make it easy for patients to navigate your website, your campus,

and their specific encounters

• Inform – make it easy for clinicians and patients to find valid and

reliable information when they are looking for it (up to date topic

specific monographs); provide important information (PH alerts, drug

recalls, relevant clinical trials) on a regular basis

• Educate – using culturally appropriate methodology for patients and

non intrusive, informative, up to date CDS for clinicians

• Communicate -- secure messaging, texting, shared EHR

• Collaborate – incorporate patient (their designated caregivers) and

all members of their care team in relevant discussions and decisions;

create shared understanding of treatment goals and revisit them

frequently.

Sharing Clinical Information: Early

Goals

• Coordination of Care at the Primary Care level

• Safe handoffs during transitions of care

• Medication Reconciliation in both inpatient and

outpatient settings

Sharing Clinical Information

Within an accountable care organization

Same EHR, same implementation

Cross-viewing

Portal technology and a Clinical Data Warehouse

Community Based HIE

With external providers

Community Based HIE

Cross-viewing

LAND and SEE technology

With patients

Patient portals

Secure messaging

Texting

Remote monitoring devices

Data Access: Early Goals

• Compute total costs of care for attributed

patients, track financials

• Predictive modeling (ID cohort appropriate

patients)

• Track quality measurements

• Know when and where your patients are getting

their care

Data Access

Create a data warehouse (quality reporting, basic

analytics, predictive modeling)

Negotiate with payers (APCD if you have one)

• Total claims data on your attributed patients (total costs of

care)

• Eligibility and benefit feeds from payers (networks, co-

pays, deductibles, etc.)

Negotiate with other providers/HIE

• ADT feeds

• Use of a shared care plan

Data Access, Integration, Analysis

Claims -- All payer data bases (including BH)

Total costs of care, program evaluation, risk sharing algorithms

Business Intelligence Analyses – Descriptive – reports, dashboards, trends, monitoring, etc.

– Predictive – applied statistics and modeling to identify priorities

– Prescriptive – linear programming and regressions to analyze options

Attribution algorithms, leakage, alternative payment methods

Social Determinants of Health

Data from multiple state agencies and departments

Community based programming

Population needs assessments

Program development and assessment

Patient derived outcomes data

Payment Reform: Early Goals

Only take on financial risk than you can handle • Upside risk only (MSSP, PCMH bonus, P4P)

• Up and down side risk -- if you can do it for about 30% of your

patient population

• Global budgets, capitation, bundled payments -- not until you’ve

proven successful in less risky contracts

Consider other than FFS/productivity remuneration

for clinicians, especially specialists

Include care outside of the office setting in

remuneration formulae

The ACO Workgroup

• Reports into the Federal HIT Policy Committee to HHS

• Meetings based on ACO/HIT Framework June-November

• Public Testimony: December 5, 20113

• Recommendations due Q1 2014

• Objective:

How can HHS (writ large) policies and programs better support innovative approaches in the AC environment, particularly with respect to HIT?

Recommendations in Discussion:

CMS Support to Adopt Robust HIT

• Increase up front funding for MSSP or funding for

including partners not eligible for MU

• Require 50% of PCPS to have met at least MU stage

1, particularly for two sided risk

• Require plan to integrate BH and physical health, using

HIT

• Require “Glide Path” Plan

• Require commitment from external care partners to

share clinical information electronically on mutual

patients

Recommendations in Discussion:

Access to Administrative Data

Claims • Support APCDs in every state through the SIM grant mechanism

• Release Medicare BH claims data

• Release Medicare claims data to potential MSSP applicants

• Explore how to integrate with clinical data

• Encounter data • HL7 standards and scalable architecture for ADT notifications to ACOs

SDH • Convene PH stakeholders to develop SDH markers for accountable care

• Support intra-state collaboration among multiple agencies and departments

Eligibility and Benefits • Make Medicare and Medicaid E and B data available 24/7 to guide cost

effective, patient centered referrals for care. Encourage commercial insurers

to do the same.

Recommendations in Discussion:

Sharing Clinical Information

Policy and Strategy • SAMHSA to issue guidelines to clarify issues re sharing BH data and work with OCR, CMS,

and ONC to modify CFR 42 if necessary to optimize care

• CMS to use survey and cert program to review timely transfer of data to care partners

• HHS to create a suitable measure for institutions sharing data and report on Compare Website

• HHS to seek ways to mitigate difficulties with institutions not willing to share clinical data

• Strengthen measures around cross vender exchange for future MU stages

• Federal ACOs must participate in local/regional/state HIE if available

Technology (Data Liquidity) • More specificity for interoperability standards for data beyond currently required

• Develop a common API for HIT applications to allow real time data sharing

• Develop and promulgate a voluntary testing and certification program limited to interoperability

for all types of HIT

• Retract ONC Certification of vendors who do not implement HIE capacity in the provider setting

Recommendations in Discussion:

Use of Data

• Accelerate progress toward a universal approach to

shared care plans (and make use part of future stage of

MU? through testing of pilots

• Bring transparency to the operative characteristics of

predictive modeling tools to identify high risk patients

• Develop a standardized algorithm for determining

attribution and encourage its use by all payers

• Measure effectiveness of CDS for improvement purposes

• Integrate data from multiple sources to increase sensitivity

and specificity in triggering CDS alerts

Recommendations in Discussion:

Administrative Simplification

Streamline quality reporting

• Align all HHS agencies and departments with respect to quality metrics

• Lead commercial payers to align measure with HHS

• Create a single quality measure repository that reflects all payers’ measures

• Assure that all measures can be calculated from existing electronic data

• Integrate claims and clinical data

HIT Standards for Administrative procedures (e.g., prior authorization,

referrals, care necessity attestations)

CMS to review burden and value of all documentation requirements

Thank You!

Access to the interactive CCHIT ACO HIT

Framework with User’s Guide

www.cchit.org/hitframework

Contact: Karen Bell MD. MMS

Former Chair, Certification Commission for HIT

ACO Workgroup member (HIT Policy Committee)

Director, JBS Center for Sustainable Health and Care

kbell@jbsinternational.com

781-801-4145 (cell)

617-834-4213 (office)