ACOs, HIE, TEFCA, and Interoperability: Has It All Become a Hopeless Federal Policy Muddle?

June 4, 2019
The release of a new report by the Office of the Inspector General at HHS is shining a spotlight on a really difficult, complex set of policy issues around accountable care, health information exchange, and other issues

Challenges involving interoperability and basic health data exchange are dogging accountable care organizations at the very time that ACOs are attempting to advance care coordination to higher levels. That unfortunate revelation has been documented in a recent analysis by the Office of the Inspector General (OIG) at the Department of Health and Human Services (HHS), as noted in a May 30 report by Managing Editor Rajiv Leventhal.

As Leventhal noted in his report, “The OIG, an agency within the U.S. Department of Health and Human Services (HHS), studied six Medicare ACOs with the goal to provide insights into how select ACOs have used health IT tools to better coordinate care for their patients.” As noted in the HHS-OIG analysis, entitled “Using Health IT for Care Coordination: Insights From Six Medicare Accountable Care Organizations,” “ACOs that used a single electronic health record (EHR) system across their provider networks were able to share data in real time, enhancing providers’ ability to coordinate care. A small number of ACOs had access to robust health information exchanges, which give ACOs access to patient data even when patients see providers outside the ACOs’ networks. Most of the ACOs we visited used data analytics to inform their care coordination by identifying and grouping patients according to the potential severity and cost of their health conditions.”

Still, the OIG report went on to state that “[T]he ACOs we visited still face challenges in these areas. ACOs that used multiple EHR systems had to rely on other means to share data among providers, either using additional health IT tools or relying on phone calls and faxes. Although EHRs are intended to streamline, coordinate, and improve care, ACOs report that EHRs can also be burdensome and frustrating for providers. ACOs also faced challenges from physician burnout due to the workload of managing EHRs. Most of the ACOs had access to health information exchanges with little or incomplete data, making it difficult to coordinate care when patients saw providers outside the ACOs’ networks. Few of the ACOs use analytics to customize care to an individual patient’s needs. Finally, few ACOs offer health IT tools to patients, other than online portals to their EHRs.”

Very importantly, in contrasting the situations in which ACOs are operating off a single instance of a single HER, versus off multiple EHRs, or multiple versions of the same vendor’s HER product, the report notes that “The ACOs that use many EHR systems do not rely on them to play a central role in coordinating care. Providers in one such ACO’s service area cannot easily share data electronically, even when using the same EHR vendor, because they have different versions of the EHR software. Instead, these providers generally coordinate care by telephone or email at the practice level rather than at the ACO level. This could impose greater burden on providers. To assist providers, the ACO has established a committee for clinical management oversight with clinician leads from its various providers. The committee discusses issues that arise across providers and shares best practices regarding care coordination.”

What’s more, the report goes on to say, “Another ACO that we visited uses a third-party tool to enable providers to share information to coordinate care, given the variety of EHR systems in use. This third-party tool includes a dashboard, updated daily, with information on patients such as recent events, lab results, diagnoses, medications, and gaps in care. The tool—effectively acting as an HIE—allows the ACO to gather data from 80 percent of participating providers across 44 different EHR systems. Four local hospitals also use the tool, which gives the ACO discharge data on 75 to 80 percent of its patient population. The providers get information on each patient’s status and can then begin to work on the patient’s post-discharge care. The ACO covers the cost of the tool for providers in its network.” Among the challenges those ACOs face, the report notes, are clinician burnout in using the EHRs involved. And, even the health information exchanges that the researchers met with, had limited or incomplete data.

Meanwhile, the release of the second draft of TEFCA, the Trusted Exchange Framework and Common Agreement for connecting HIEs, has spurred further confusion and controversy among provider leaders over what federal healthcare officials’ intentions are in terms of how accountable care, health information exchange, and other phenomena will work together going forward. How will all these complicated pieces fit together???

Indeed, it is in the context of multiple federal healthcare policy trajectories that all these findings in this new report are troubling and concerning, particularly at a time when Seema Verma, Administrator of the Centers for Medicare & Medicaid Services (CMS) has been intensifying her calls for ACO leaders to take on two-sided risk, with recent proposed rules and schedule development potentially alienating currently participating ACO organizations, particularly in the Medicare Shared Savings Program (MSSP).

So it feels as though several very different, perhaps even conflicting, developments are evolving forward at once. First, ACO leaders continue to develop forward population health management and care management strategies in their organizations, consonant with their contracts with payers (federal, state, and private), and with their desire to improve health outcomes for their attributed plan members/beneficiaries/patients. Second, at the same time, ACO leaders are discovering the limits inherent in working with multiple EHRs and attempting to execute on population health management and care management, in that context.

Yet at the same time, one of the key tools available to them to overcome some of the challenges they’re facing, the use of HIEs, is also now very much in question in terms of the parameters that federal health policy officials, including Verma, want to shape for them.

For example, what will happen to the current initiatives of the Sequoia Project, Carequality and the CommonWell Health Alliance, two industry alliances dedicated to moving U.S. healthcare dramatically forward around interoperability? Some industry leaders are deeply concerned that whatever ultimately comes out of TEFCA, could set the industry back rather than taking it forward, particularly as the industry-spawned entities begin to truly bear practical fruit. (As it notes on its website, “In 2018, The Sequoia Project updated its corporate structure to reflect the continued maturation of the organization and the significantly larger role that The Sequoia Project plays as the central convener for interoperability. The updated corporate structure resulted in The Sequoia Project having two distinct subsidiaries, one for eHealth Exchange and one for Carequality. Following the reorganization, The Sequoia Project continues to bring together industry and government to transparently and inclusively develop solutions to the most pressing challenges of health data exchange.”)

So one can only express deep concern over the complexity involved in the current healthcare policy moment. Things appear more tangled and complex than ever; and only time will tell whether Seema Verma and the other senior federal healthcare officials will be able to guide the industry forward towards clarity and direct purpose, in order to move successfully into the next phase of U.S. healthcare industry evolution. Honestly, it’s hard to predict exactly what’s going to happen next with all this. But the leaders of patient care organizations will need to remain hyper-alert—and honestly, hyper-vigilant, as they monitor the landscape going forward. And it’s clear that the next two years will be pivotal for the future overall direction of the industry, along so many dimensions. Clearly, the bottom line here is, stay tuned.

Sponsored Recommendations

Going Beyond the Smart Room: Empowering Nursing & Clinical Staff with Ambient Technology, Observation, and Documentation

Discover how ambient AI technology is revolutionizing nursing workflows and empowering clinical staff at scale. Learn about how Orlando Health implemented innovative strategies...

Enabling efficiencies in patient care and healthcare operations

Labor shortages. Burnout. Gaps in access to care. The healthcare industry has rising patient, caregiver and stakeholder expectations around customer experiences, increasing the...

Findings on the Healthcare Industry’s Lag to Adopt Technologies to Improve Data Management and Patient Care

Join us for this April 30th webinar to learn about 2024's State of the Market Report: New Challenges in Health Data Management.

Findings on the Healthcare Industry’s Lag to Adopt Technologies to Improve Data Management and Patient Care

2024's State of the Market Report: New Challenges in Health Data Management