Accountable care to improve the health of communities

Despite annual healthcare expenditures exceeding three trillion dollars per the Center for Medicare and Medicaid Services (CMS), the United States is not achieving the health outcomes and quality that are desired for its population. In response to the challenges facing the health of communities, CMS has continued to launch programs for Accountable Care Organizations (ACOs) to support networks of providers responsible for the overall healthcare of an assigned population of Medicare beneficiaries.

The goals of an ACO are to improve the patient experience of care (quality and satisfaction), improve the health of populations, and reduce the per-capita cost of healthcare. To achieve their goals, ACOs need to acquire health IT solutions to support the community oriented, risk-based care approach that is needed for highest performance. When an ACO manages utilization of healthcare services, keeps total costs below set benchmarks, and meets defined quality measures, it earns a portion of the difference between the benchmark and the actual total cost of care. ACOs offer hope to the healthcare system by focusing not only on individual patients with individual diagnoses, but also the health and wellness of the community. Here are some specific technology requirements for ACOs.

Interoperability

ACOs are responsible for the health of an assigned population—patients who may be geographically dispersed, receiving care from several hospitals, clinics, and independent specialists. To coordinate care and effectively use analytics, ACOs must aggregate and integrate clinical data from multiple sources across the community and deliver it in real time at the point of care. Challenges with electronic health record interoperability makes the aggregation and presentation of longitudinal patient records a difficult task considering the critical need to bring together other types of data (e.g., claims or financial data) from potentially dozens of systems in an efficient manner. Without the ability to leverage sufficient data, providers have difficulty succeeding in coordinating care to address any gaps while eliminating redundancies in care.

Risk stratification

Understanding the clinical and financial risk within the assigned population is critical. Providers should manage risk by identifying their most expensive patients and grouping them by disease registries (e.g., diabetes or hypertension) to identify proactive and preventive care management approaches and reduce the need for high-cost, episodic care. Sophisticated risk stratification tools that consider clinical and claims data, financial information, social determinants, and behavioral factors and that employ predictive analytics can achieve more precise results and help organizations determine where to focus constrained care management resources to achieve the highest return.

Care management

Proactive, preventive care management helps reduce the likelihood of high-cost episodes of care. The challenge for organizations is how to scale care management activities and find efficiencies that enable a care team to deliver care more efficiently and consistently across a large population. Manual processes and a lack of efficiency lead to delays in improved outcomes and inconsistencies in care, which contribute to higher costs. Tailored software applications enable providers to streamline care management workflows and achieve the efficiency and scalability that drive positive results across a variety of valued-based programs, including Medicare Shared Savings Program, Comprehensive Primary Care Plus, Bundled Payments, etc.  A flexible and configurable solution “future proofs” the organization to accommodate new programs that may be launched.

Clinical workflows and data analytics integration

ACOs understand the value of using data and analytics to improve the quality of care and lower costs, but many have not yet integrated data and analytics directly into clinical workflows where they can have the greatest impact. ACOs need IT solutions that surface valuable data and analytics (e.g., gaps in care, risk scores, full medication histories) into clinical workflows to improve care while a clinician is still in the presence of a patient. Given that population health is a team-based activity involving a variety of clinicians in different facilities, analytics that reveal cost and quality results surfaced in clinician workflows help close gaps faster and improve patient outcomes.

How IT can support ACOs in delivering effective and efficient population health management

ACOs need strong capabilities in each of the following areas:

1. aggregate data from across the community to connect all clinicians responsible for a targeted population,
2. stratify populations to prioritize resources to the programs that will deliver the greatest impact on patient outcomes,
3. target care management activities to increase preventive and primary care for prioritized patients, and
4. surface clinical, cost, utilization, and quality information at the point of care for all providers.

Providers should address population health as a series of interconnected activities rather than as distinct, siloed efforts. IT solutions need to create a unified user experience to support the interconnectedness that plays an integral role in an organization’s strategy: providing a stronger understanding of a community’s needs and supporting efficient, targeted care.  ACOs should integrate an enterprise solutions portfolio encompassing the capabilities critical to delivering effective population health management, including data control, healthcare analytics, and care coordination and engagement. They also should seek vendors with the experience to provide advisory services and demand short implementations to ensure rapid time to value.