Population Health IT for ACOs: A Patchwork Quilt
by Ron Parton, MD, MPH, Chief Medical Officer of Symphony Corporation
The new ACO rule has big implications for information technology. In the final rule
on accountable care organizations (ACOs), CMS has included 33 measures that
report overall performance while allowing providers options to share in any
savings. Because the new ACO rule will no doubt steer payors and providers to
improve quality and reduce costs, the need for population health information technology
to support ACOs has dramatically increased.
Current reporting technology and electronic health records (EHRs) may be able to
provide basic reporting on the measures, but they are woefully inadequate at meeting
the ACO requirements for improving care, enhancing the patient experience and
reducing costs. New population and care management systems will be required to
support primary care medical home models, care coordination, case management, and
transitions of care. Advanced health care delivery will require the adoption of new
information systems and tools that:
• Provide rapid, flexible and continuous performance reporting
• Promote the proactive identification and management of the “highest risk” patients
• Accurately attribute patients to physicians and care teams
• Allow care teams to coordinate care across the entire continuum and
systematically manage multiple chronic illnesses
• Integrate information and work flows across population & care management
systems, EHRs, care teams, providers, community resources, and health
information exchanges (HIEs)
• Support “real time” decision making and population surveillance using evidence-based guidelines
• Engage, educate and support patients in self-care, prescription drug adherence, lifestyle improvement and prevention
• Aggregate and manage data from multiple disparate data sources (clinical, administrative & financial) with a reliable master patient index functionality
An array of technologies and information tools to piece together: A patchwork quilt
Integrated delivery systems such as Kaiser Permanente, Geisinger and Group Health Cooperative have incorporated population health information technologies to varying degrees to improve quality, reduce costs and enhance patient experience. These leading organizations found their EHRs insufficient for population health management. Since their electronic health records lacked this functionality, they ultimately developed and/or bought, and then pieced together their data, systems, tools and reports. In fact, these systems have spent a considerable amount of time and money on creating these tools themselves. These collections of support tools, registries, and systems are far from perfect, but have allowed these organizations to accomplish impressive results that have set them apart as national leaders in managing quality and cost. Organizations of physicians and hospitals that are striving to create ACOs can build on the experience of these integrated systems to improve their performance under healthcare reform. Building on top of an EHR, the following components create a population health IT system:
Data warehouse/data repository – Integrating multiple data sources including ambulatory and inpatient EHRs, labs, scheduling, billing, health information exchanges (HIEs), insurance claims, remote monitoring, patient selfreports, research, demographic, administrative and financial data
In general, the data warehouses that are included with EHRs are not designed for integrating financial, clinical, research and administrative data from multiple external sources or for use in tracking health care interventions and outcomes for populations. To improve and report on performance, an ACO will need to create a data warehouse and/or repository to store all available data on its patients and services and make these data available across the enterprise to support the population and care management initiatives.
Population health and care management system – Including an enterprise multi-disease registry with measures and reporting; work flow support & tools for case management and health coaching; care team performance tracking with an embedded rules engines to support follow-up tasks and reminders; creation and sharing of care plans that include longitudinal care views of goals and progress.
Chronic illness registry tools typically have been developed for single diseases and have produced lists of patients that need follow-up or have “care gaps”, but do not include case management tools or health coaching functionality to manage and/or document the work in coordinating care and assisting patients with their illnesses. These tools help to facilitate identification and can report the results, but they do not manage the workflow across multiple diseases or support case management/health-coaching. New population health and care management systems are now available that are multidisease and can help care teams with role-based task management, care coordination, prescription drug adherence, patient letters and reminders, life style tracking to goals, and comprehensive clinical and financial performance reporting. These population health and care management systems are complementary to and can integrate with EHRs. They are designed to be flexible and accommodate different work flows across the care teams and also allow for the inevitable changes in measures, definitions and guidelines that will occur from time to time with medical advances.
Population surveillance rules engine – To monitor care process and outcomes using evidence-based guidelines, with links to both a population and care management system and the EHR
Most EHRs will facilitate reminders that “pop up” during a patient encounter to flag the need for routine preventive screenings, immunizations, lab tests and care gaps, but they are not very flexible and do not connect to a follow-up tracking system that facilitates role-based work flow for the care team. Since EHRs are visit-based, they generally don’t trigger actions between encounters, don’t allow flexible workflows for follow-up across the care teams, and don’t document interventions or communication attempts. Evidence-based rules engines that exist outside of the EHR can support population management by the care teams for actions that are triggered, often avoiding the expense of a face-to-face visit with the practitioner. There are population health and care management systems that incorporate evidence-based rules engines for population surveillance and support care teams in closing the care gaps that are identified.
Clinical integration of systems - Integrates population health IT with
EHR functionality and work flow
While much of the routine population health and care management work can occur outside of the typical physician encounter, freeing up physicians to concentrate on the more urgent issues, difficult medical problems and complex patients, the complete set of information about each patient must still be stored in the EHR. This requires that new information generated in a population and care managements system be fed back to the EHR, so it is available at the point of care for decision-making and follow-up. In addition, there may be actions that are triggered in the population and care management system such as scheduling a lab appointment, a change in a prescription drug and/or a follow-up physician appointment that can be executed in the EHR. The work flow between the EHR and the population and care management system must be optimally integrated to help assure efficiency and access to the data. Over time, some of the population health functionality that isn’t available now may be incorporated in the EHR itself. However, EHRs are usually structured around encounters rather than populations, care teams, or non-encounterbased workflows. This may ultimately limit the capacity of most current EHRs to incorporate population health IT functionality.
Advanced reporting - Tracking financial, administrative and clinical performance
Decision making to support improved quality and reduced cost requires a full set of internal financial, administrative and clinical performance reports that measure their own performance against benchmarks as well as a full set of external reports for pay-for-performance programs and reporting to third parties including HEDIS, PQRS, ACO measures and statewide quality collaboratives.
Analytic tools – Focused on predictive modeling, episode grouping, severity & case mix adjustments
Predictive modeling tools (i.e. Johns Hopkins ACGs or Medicare’s HCCs) support proactive identification and stratification of the highest risk patients for potential referral to complex case management. A parallel methodology is also needed to measure cost and utilization with case mix adjustment, typically through episode groupers (i.e. OptumInsight’s Episode Treatment Groups or Thomson Reuter’s – Medical Episode Groups).
Remote monitoring technologies – Home-monitoring that interfaces with care management and EHRs
High-risk patients with certain chronic illnesses such as congestive heart failure, diabetes, hypertension and chronic obstructive pulmonary disease may benefit from utilizing home-monitoring devices that allow them to track their own illnesses and work interactively with a case manager and/or health coach that can also follow and track their outcomes in “real time.” This information can be sent back to both the population and care managemen systems and the EHRs.
Patient and family engagement technologies – Including web-based portals linked to personal health records; life style tracking tools; handheld technologies for education, tracking, reminders and interactive learning; webvideo technologies for virtual provider visits, health coaching and case management; and interactive assessments, questionnaires and connectivity to measure patient outcomes and provide feedback on patient experience
Patients are now being provided access to their own medical record information and encouraged to learn more about and manage their own health risk factors and chronic illnesses. Mobile and tablet technologies, web-based patient portals and web-video technologies are allowing patients to have better access to their care teams, medical knowledge and tools that help them to improve their lifestyles and achieve better results in managing their illnesses. These can be linked to both their population and care management tools and their EHRs. Patient experience questionnaires, interactive assessments for depression screening, assessment of activities of daily living, pain management follow-up, etc. can be administered using email, patient portals and/or handheld technologies. This information can be stored and tracked in the data warehouse and the EHR as needed. Families are using some of the same technologies for social engagement and monitoring.
Population Health Information Technology is Complex to Implement but Critical for ACO Performance
All the pioneering organizations participating in the Medicare Physician Group Practice demonstration, such as Marshfield Clinic, have significantly redesigned care workflows and introduced population health information technology that makes clinical data more readily available to the practitioners and care teams, including additional “add on” disease registries or embedded tools within their EHRs.
It may be disappointing that after having spent significant amounts of time, effort and money to implement electronic medical records across your own organizations, there is more work ahead in assimilating a complete set of population health information technologies to become a successful ACO. The consolation is that none of these pioneering organizations have used all of the population health and care management tools that are now available and yet most of
them accomplished positive results.
One of the keys going forward will be to prioritize the functions that are most likely to achieve results and implement those first. See the Appendix below for a matrix of Population Health IT and functionalities:
Dr. Ron Parton is Chief Medical Officer of Symphony Corporation, a global technology solutions provider based in Madison, WI. He may be reached at email@example.com
Accountable Care News is a publication of Health Policy Publishing, LLC.
The title of this blog should read more accurately “How Private Duty Home Care, Home Health Care, Therapy agencies, Infusion, Geriatric Care Managers, those providing care for the elderly or planning for care transitions can THRIVE in this era of Health Care Reform” …. BUT that just doesn’t fit in the title block.
Put the incentives in the hands of those who deliver care and solutions that include telehealth monitoring, wellness coaching, early preventive care, toenail clipping, and free rides to appointments will take over. When organizations are accountable for the results and the costs, incentives are aligned. Providers are no longer consumed with fee for service and they are rewarded for being effective and efficient. These models can simultaneously improve the quality of care and reduce overall costs.
Here’s proof – and every Private Duty home care agency, Medicare certified Home Health agency, hospital, and physician providing Geriatric Care had better get on board:
CareMore, now owned by WellPoint, started bucking the fee-for-service trend in healthcare decades ago. CareMore’s founder, Dr. Sheldon Zinberg, envisioned a coordinated care model for the elderly that focused on early interventions and preventive care.
A lesson from business: A problem that costs $1 to solve early will cost you $30 to solve if you wait for it to become a big problem. It’s a principle proven repeatedly over the last 80 years or so since Deming first explained it and it is a fundamental axiom of business. Toyota and Proctor & Gamble live by it, and it drives a culture of both quality and cost management. Accountable Care Organizations understand it and will embrace it, as well.
Consider this example, all too common with elderly patients, borrowed from “The Quiet Healthcare Revolution,” in November issue of The Atlantic Monthly and written by Tom Main and Adrian Slywotzky.
“Ellen, an 82-year-old widow, lives in Anaheim, California. One Wednesday morning last year, she got on her scale, as she does every morning. One hundred and forty-six pounds—wasn’t that a little high? Ellen felt vaguely troubled as she poured herself a bowl of oat bran.
Half an hour later, the phone rang. It was Sandra at the clinic. She too was concerned about Ellen’s weight, which had jumped three pounds since the previous day. Sandra knew this because Ellen’s scale had transmitted its reading to the clinic over a wireless connection.
Given that Ellen had a history of congestive heart failure, a three-pound weight gain in 24 hours was a potentially dangerous development, a sign of possible fluid buildup in the lungs and increasing pressure on an already stressed heart. Sandra wanted her to come in for an immediate visit: the clinic would provide a car to pick her up and bring her back home. Ellen’s treatment began that very morning and continued for two weeks until she was out of danger. Had the warning signs not been noticed and addressed so quickly, she might easily have suffered a long, painful, and expensive hospitalization. “
Another example from the same article in The Atlantic:
“Dan, a retired letter carrier, is a patient at a clinic in the same system. At 87, he is decidedly frail, his once-sturdy legs now weak and unsteady. He is a classic candidate for a fall of the kind that has injured many of his friends, in some cases leading to weeks in the hospital and months of rehab. The elderly are prone to falls for many obvious reasons, including weak limbs, impaired vision, and medication side effects. But Dan’s doctors knew that some less obvious causes included shag carpets and long, untrimmed toenails. Because of this, they’d sent someone from the clinic to visit Dan’s apartment and make sure that his daughter replaced the 1980s-vintage carpets with low-pile rugs. Dan also visits the clinic regularly for light muscle-training sessions and periodic toenail clipping. Due to these preventive measures, Dan and his fellow clinic patients are one-fifth as likely as comparable patients elsewhere to suffer falls.”
Ankota's XChange Care Coordination Portal helps providers coordinate roles and assignments in Accountable Care models such as these. The Xchange Care Coordination Portal is part of Ankota's Healthcare Delivery Management technology (HDM), which helps individual providers make their own operations more productive and efficient.
Pointer Ware caught my eye as a terrific bridge to connect seniors with technology, and I thought I would share it along with a few comments about why this type of technology is so important. Take a look and read on.
This is not an endorsement of the product, rather an endorsement of its purpose. Based on what I have learned about Pointer Ware, it seems this technology accomplishes a few, very critical things:
1) It makes it easier for seniors to engage in the "connected" world. One of the scariest and most troubling parts of aging is the isolation that seniors often feel from their family and their communities. The second fastest growing segment on Facebook is people age 65+. As people age, they often want to reconnect with people and memories from their past. It has been said that technology breaks down boundaries. As people age and become less mobile, they feel there are more and more barriers preventing them from leading normal, social lives. Technology is an ideal way to eliminate many of those boundaries and help them to connect with friends and family more, without geographic restriction. Anything that helps people overcome the fear and uncertainty of engaging with technology—whether Facebook, Skype, or email—is a good thing. That’s why I like Pointer Ware’s approach. It’s all about making technology accessible to seniors, which can help them participate in the connected world.
2) Technologies like Pointer Ware help seniors live longer in their own homes. Because they feel better connected while in their own home, technologies like this make it possible for seniors to live in their homes longer. One of the biggest arguments for assisted living facilities is that they provide a social structure and community of peers. It is well understood that seniors need this social structure to thrive (just like you and I do—they are no different). However, it is also well known that seniors are happier and healthier in their own homes and prefer to live there as long as possible. Technologies like Pointer Ware allow them to do that, which improves overall quality of life. Of course, there is significant financial advantage to living at home longer, too. Assisted Living Facilities are expensive—living at home much less so. It is clear that there are both social and financial advantages to supporting seniors at home as long as possible.
3) The future of senior care will be enabled largely by advances in technology. As a result, there is tremendous demand for technologies that make other technology more accessible to seniors. It’s all about user interface. To state the obvious, if we make more senior-friendly interfaces to technology, then more seniors will have more ways to engage with technology. As this happens, many new types of services will be able to be provided to this booming population. Senior friendly interfaces will provide launch pads or integration points for new technologies that will help improve their lives. Technology must encourage this.
Many of Ankota’s customers provide Home Health care services, Physical Therapy and Occupational Therapy, or Private Duty care for the elderly. Companies like Vital Partners 365 are leading the way in remote monitoring or telehealth monitoring services, much of which is done for the elderly. Monitoring devices like Honeywell HomMed make it easier for companies like Vital Partners 365 to provide these services. Ankota’s own FamilyConnect is intended to bring family members into the conversation more consistently with alerts and communications from caregivers, supporting one of the key social structures that seniors depend on. Technology and services will continue to meet at an increasing rate to serve the aging population.
The more accessible technology becomes to seniors (and their families), and more comfortable seniors are with technology, the better able they are to participate in their own care. Imagine a world where not only does the technology monitor vital signs and certain activities remotely, but the patient is better able to interact with those who provide their care. People who are more involved in their own healthcare feel empowered and are more committed to the results. They feel safer and live happier, longer lives.
By 2030, estimates say that 30% of the population will be 65+. A few decades ago, the 65+ population made up barely 7%. This presents a huge market with tremendous spending power (just ask AARP!). They simultaneously present a massive burden to the healthcare system and tremendous opportunities to businesses that provide care or create technologies that enable better care. Helping seniors feel more comfortable with technology will provide for better, more creative and cost effective solutions.
As technology better serves them, seniors will live happier, more fulfilling lives.
My friend and colleague Laurie Orlov posted another gem on her blog entitled “Tech-enabled home care is betwixt and between” which you can read here. For those unfamiliar with Laurie, her website and blog is called the Aging in Place Technology Watch and can be viewed at http://ageinplacetech.com. As the title implies she focuses on technology for aging in place. From a style perspective, she has a snarky way of pointing out iniquities in understanding the way that technology and aging are being used and should be used. This makes her posts very entertaining. She’s also a great researcher which makes her posts well-informed and educational.
In a nutshell, Laurie looks at the high costs of elderly care in assisted living facilities (ALFs) and Home Care and then looks at how the Kentucky-based company ResCare has 50,000 employees helping 1 million clients by checking in on them using home monitoring technology combined with web-cam and chat capabilities. The caregiver checks in on the individual or couple remotely in their home, and has the ability to get them help only when needed. In the case of ResCare, most of their cases are reimbursed through Medicaid.
Laurie then points out that so far as she knows there aren’t a lot of private pay home care organizations using this type of technology to lower their costs or differentiate their service. In our home care entrepreneurship series on the Ankota blog, we suggested a blueprint for this several months ago that you can read here, but in a nutshell, here’s the idea:
- Offer a service to install TeleCaregiving technology such as the products offered by Ankota's partner BeClose. For this you can charge a site-survey and installation service fee
- Next offer a bundled service where you check-in on the client on a regular basis (weekly, monthly, etc. based on their need)
- Couple it with Ankota’s FamilyConnect which gives you a way to report back to the loved ones of the person under your care
- Also offer the ability to deploy a caregiver when needed (at a higher than normal price because of the on-demand nature of the service)
What does this give you:
- A low-priced yet high margin entry-level caregiving service that you can offer in your community
- A way of building a relationship with prospective clients long before you currently do
- A great shot at being able to provide in home care as the client’s needs escalate
Ankota provides software to improve the delivery of care outside the hospital. Today Ankota services home health, private duty care, DME Delivery, RT, Physical Therapy and Home Infusion organizations, and is interested in helping to efficiently manage other forms of care. To learn more, please visit www.ankota.com or contact Ankota