Managing the data needs within accountable care organizations (ACOs) is anything but business as usual. First, many of the quality and performance measures required by the Centers for Medicare & Medicaid Services (CMS) are more holistic quality-outcome measures, and are therefore relatively new concepts for hospitals and physician groups. Second, the data and information exchange requirements to effectively manage risk and quality outcomes within an ACO are extremely complex.
Success in the ACO environment requires the ability to influence a wide range of metrics to right-size utilization, mitigate care gaps and enhance care coordination. Unless participating providers are able to assess and act upon data in real time, they will not be able drive the quality and cost improvements necessary to maximize reimbursements and share in cost savings.
Thus, the data management challenge for ACOs is two-fold: 1) gathering information from multiple sources and converting it into role-based, actionable data and 2) creating a technical infrastructure that enables rapid data analysis and information exchange with providers to effectuate needed interventions.
ACOs are plan-like entities operating in a fee-for-service (FFS) system. Their success or failure hinges upon the ability to drive down costs and improve quality. This can only happen by bringing together clinical and administrative data - including enrollment, eligibility, demographic and claims data on assigned beneficiaries - from multiple disparate sources to create comprehensive, sharable and actionable clinical histories for each patient.
A first step is closing providers' knowledge gaps when it comes to the outcome-centric measures (usually tied to health plan performance) CMS will use to determine the ACOs effectiveness, such as National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures. In particular, ACOs must convey to participating providers how this data can be leveraged to influence performance outcomes and quality scores in real-time through continuous monitoring for and remediation of care gaps.
To drive appropriate outcomes, ACOs must also leverage advanced business intelligence to ensure participants utilize clinical and administrative data in ways that ultimately improve care coordination and utilization. For example, proactive patient assessments identify high-risk individuals or those with multiple comorbidities or chronic conditions so chronic care and preventative health needs can be properly addressed. More efficient and effective interventions can be enabled through proactive case, care and disease management, while patient safety and utilization management can be improved through comprehensive medication reconciliation and drug monitoring.
An Integrated Architecture
Just as ensuring that ACO participants have access to needed clinical and administrative data requires an innovative and integrated approach, so too does addressing the technical barriers preventing that access. A traditional approach to constructing a technical infrastructure capable of addressing an ACO's complex data requirements carries costs that are prohibitively high for many healthcare organizations. Other technical challenges include the lack of interoperability among the multiple legacy systems in use by the various participating organizations as well as establishing the required connections with CMS.
It's important to note that this infrastructure will require a much broader reach than simply deploying an electronic medical record (EMR) system. While EMRs are critical components and should be integrated as part of the greater technology strategy, they will not provide the information-sharing capabilities needed for comprehensive data analysis. An ACO will essentially need to operate as a health information exchange (HIE) where clinical, financial and utilization data meet to address care gaps and improve the efficiencies and quality of care delivery.
By deploying integrated care management, quality and compliance software platforms, ACOs are able to efficiently and affordably eliminate the majority of the technical barriers. These platforms leverage open standards to eliminate interoperability issues, thereby facilitating secure connections and real-time information exchange regardless of existing legacy systems. In addition to keeping upfront and ongoing costs low, this flexibility allows for deployment in weeks rather than the months (sometimes years) required for traditional deployment.
Web-based integrated platforms, which allow provider access and management, also allow ACOs to custom-configure functionality and deploy tools that target metrics which have the greatest impact on quality scores based on populations served. These should ideally include predictive modeling and stratification tools, as well as tools to identify HEDIS, Star and other care gaps and trigger appropriate interventions. Other desirable features include the ability to generate member, provider and local population profiles, risk score calculators and case/disease management modules that enable assessments, care plan creation and real-time monitoring and fulfillment of clinical and social interventions.
Innovation & Integration
The data needs of ACOs are complex. From the technical challenges of collecting and exchanging data from multiple systems across multiple organizations to the knowledge gaps encountered when providers begin utilizing outcome-centric data to drive care decisions, ACO planners are quickly discovering that a traditional approach creates more barriers than it resolves.
By leveraging integrated care management, quality and compliance platforms, ACOs are able to cost-effectively establish the connections necessary to share the complex data necessary to track quality and performance measures and influence clinical outcomes. They drive systemic improvements by establishing a clear understanding of quality and utilization metrics, individual performance in relation to those metrics and the relationship between quality outcomes and financial rewards.
An integrated and innovative approach to care management, quality and compliance helps ACOs ensure that participants have access to the information they need to better manage patient populations. This, in turn, enables the ACO to achieve the cost and quality outcomes necessary to participate in shared savings.
Anil Kottoor is the CEO and president of MedHOK, a provider of cloud-based modular software that leverages the cloud to enable organizations to meet quality, care and compliance objectives across healthcare business lines.