ACO Management Depends on IT

There will be wide variability in the types of accountable care organizations that are established in the near future. Some will be tightly organized around existing integrated delivery networks. Others will be based on independent physician associations without an integrated hospital. Still, others will be formed as a collaborative multi-stakeholder initiative, perhaps building from a sustainable health information exchange. There will be distinct payer relationships.

Some ACOs will be Medicare-specific, others focused on Medicaid managed care and others multi-payer. As the health benefit exchanges become established there will be an additional stimulus to the development of ACOs—some with integrated insurance functions, others operating in partnership with managed care plans. 

No matter what the particular ACO form, six key success factors will be critical for successfully delivering on the potential of accountable care. As the ACO becomes more mature, the breadth of information technology necessary also will increase so as to provide the connectivity and the decision support needed to manage the continuum of care.

Table 1 – ACO success factors and the characterization/focus of each associated with start-up, developing and mature ACO organizations. 

ACO member engagement

The underpinnings for ACOs will be a patient-centered system of healthcare, in some cases organized around primary care-based medical homes; in others organized around health maintenance and clinical care processes; in others around specialty medical homes optimized for specific diseases.

The ACO member engagement objective for an ACO is to enable self-service for members to participate in their own care and to manage their administrative and financial interactions easily, efficiently and conveniently. 

Patient portals that provide access to an underlying EHR, available online and via kiosks, give patients access to clinical support, such as secure provider messaging, reminders, alerts, test results views and prescription refill requests. Personalized to the patient or member, the portal will also contain access to tailored health information and provide access to customized health maintenance modules for conditions such as smoking cessation, weight loss, depression and nutrition. Portals will also enable ACO members to connect remote physiologic monitoring devices such as blood pressure cuffs, scales, heart monitors and other remote devices for transmission of real-time data to tracking systems utilized by their care providers. 

Clinician contact center support—that integrates real-time chat—also has proven to be of significant value in serving patients more effectively. Portal functionality must also support administrative and financial tasks including access to registration, appointment scheduling, messaging and other systems that make it easier for members to access (and therefore enhance relationships with) providers in the ACO network. Social media applications include patient-to-physician secure messaging (including instant), use of Twitter and social networks to support adherence to health regimens, physician profiles and blogs similar to Facebook pages, and user-generated content that will range broadly from provider evaluations to reports on treatment.  

Cross continuum medical management 
The HIT starting point for supporting cross continuum medical management is the patient electronic health record that can be partially or completely transferred or shared between and among referring and receiving providers. An enterprise EHR is a fully integrated system that gives each user (at the hospital, practice, and other ACO sites) an opportunity for customized views and templates for entering and retrieving patient clinical data and information. It uses a common patient database that gives each user real-time access to all relevant patient information available within the ACO, based on their assigned privileges, security access and "need to know." 

In many ACOs, an enterprise EHR will be out of reach, but other options such as HIE networks that transfer patient record summaries have proven to be an effective compromise, and use of portals that providers can use to review partial EHRs, such as online test results, progress notes and discharge summaries, are a great starting point. Other HIT tools that contribute to cross continuum medical management include:

• Consistent EHR (and HIE) clinical content across venues, such as patient record summaries, health risk assessments, care plans, problem lists, medication lists, discharge plans, standard order sets, visit and other EHR charting templates, and compatible clinical vocabularies.
• Access to online guidelines and protocols—implemented both as look-up features and as built-in content, such as in charting templates—for management of target conditions with an ongoing evaluation (derived from both claims data, as well as clinical transaction data) of compliance by the practitioner. 
• Consistent clinical decision support rules and alerts across distinct EHR systems and the continuum of care.
• Provider communication tools, such as options to include notes with referral and transfer orders, and in-box or other messaging modules.

Clinical information exchange
Care coordination and collaboration rests on a foundation of clinical information sharing. A fundamental question ACOs need to answer as they assess HIT requirements is how to provide HIE access. The most popular options are implementing a private network or using one or more public networks such as those offered by regional health information organizations (RHIOs) and being developed for statewide use.  Trade-offs are not surprising. Private HIEs provide more control over things like volumes, data and data formats supported, and expansion, but can take time and can be expensive to implement; while RHIOs, for example, often offer immediate access at defined costs, but sometimes cannot accommodate special needs and have rigid data and data format standards. 

Quality reporting
In order to qualify for Medicare Shared Savings Program and other ACO initiative programs, ACOs will have to provide reports that demonstrate meeting quality of care performance thresholds (among ACO member populations) as defined by CMS and/or other payers and sponsors of their programs. These requirements are increasingly being derived from clinical-based (EHR) data. Furthermore, the pressure from value-based purchasing requirements is spurring the need for real-time quality reporting data and information, such as supporting the collection of clinical core measure information reporting on patient conditions, such as AMI, CHF (including condition on admission and risk for readmission), pneumonia, as well as on hospital-acquired conditions such as sepsis, deep vein thrombosis / pulmonary embolism, and glycemic control. Real-time reporting solutions that provide the clinician with actionable information will be an essential tool in managing high-cost inpatient services and preventing avoidable readmissions.

Business intelligence, predictive modeling and analytics
Placing information about individuals in the context of the larger assigned population allows information management and analytical processes to account for the larger scope of ACO obligations to provide high-quality care at acceptable cost, as well as to ensure favorable clinical and financial outcomes for the assigned population. Creating a complete data set for the ACO population will require integration and rationalization from multiple sources and systems including:

• Patient level data within the ACO: clinical transactions from EHRs, lab and imaging, and information from pharmacies and physician practice management systems
• Patient level data from outside the ACO: clinical transactions from out of network providers supplemented with claims data from health plans and pharmacy benefit managers
• Member level data from non-traditional sources: health risk assessments and self-care and wellness regimens

Applying business intelligence and predictive analytics to the data set will inform improvements in patient care processes and activities across the continuum of care and to risk and financial management activities as well. 

Applying predictive clinical analytics allows the ACO to monitor care patterns, to assess adherence to protocols and best practices, and to anticipate future needs and patient requirements. This effectively creates the continuous feedback loop required for ongoing process improvement. Similar predictions can be made based on analysis of financial information and risk patterns to inform risk management activities and financial management activities as well.

This ability will be especially important in the negotiation and management of payer contracts, where the ACO bears financial risk for clinical outcomes, and will require finely-tuned abilities to predict acuity, utilization and the cost associated with the responsibility for the care of the defined population.

  ACO Risk and revenue cycle management
Managing the risk and financial responsibilities of an ACO will require a fundamental reorientation of traditional revenue cycle activities. As the focus of financial and administrative processes changes to include the entire assigned population, ACOs will require an information system that allows them to recognize and capture information before, during and after the period when individuals become patients—in effect, managing beneficiaries rather than patients. Health plans use membership repositories and membership management systems for this function and ACOs will need to quickly adopt similar systems and processes to ensure that they can properly identify, monitor and report on all the activity associated with their population. 

Traditional cost accounting and patient accounting systems and processes must be assessed, and likely expanded as well. ACOs must provide a complete spectrum of services in a variety of health care settings, any or all of which will present new accounting and billing requirements and capability.  Provider network management and contract management will determine ACO investment in applications and processes that will allow them to manage and distribute ACO revenues to all the participants in care delivery and patient service. The specific application requirements will vary based on employment and contracting models among the entities that combine to form the ACO, but it is likely that large-scale ACO organizations will require the ability to administer and process claims for healthcare services—perhaps in order to pay providers, but certainly in order to measure and monitor provider productivity and population utilization of services.

HIT investments to achieve ACO status will go well beyond those required to address other current HIT trends, such as meeting EHR meaningful use criteria, converting to ICD-10 coding standards, and evolving pay-for-performance and value-based purchasing initiatives. As a result, organizations aspiring to ACO implementation need to carefully consider how they allocate spending for HIT along with other demands over the next decade. 

The diversity of applications and tool sets increasingly available present a dizzying array to the CIO and the ACO clinical and administrative teams. A sourcing strategy will be required which can specify when to rent, outsource, build, buy or partner with other organizations to realize HIT solutions. At times, knowing when to wait for the market to catch up with affordable technology and/or service solutions will be the best approach while at other times, getting out in front will present clear advantages.

For all these reasons, organizations planning to implement and operate an ACO need an overall HIT roadmap that links capability development with the maturation and evolution of their ACO. That roadmap needs to include individual system and application tactics and strategies that fit into a long-term agenda for sequencing and implementing them tied to the ACO's growth in responsibility for managing patient populations. 

Tom Enders is Managing Director at CSC's Healthcare Group,and may be reached at tenders@CSC.com. Jordan Battani and Walt Zywiak are Principal Researchers at CSC's Emerging Practices, the applied research arm of CSC's Healthcare Group.