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Health IT Summit Boston - Presentation "HIT Roadmapping for Accountable Care" with Karen Bell


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Karen Bell, MD, MMS …

Karen Bell, MD, MMS
Director, Center for Sustainable Health and Care
JBS International, Inc.
Former Chair
Certification Commission for Health Information Technology

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  • 1. HIT and Accountable Care
  • 2. Today’s Objectives 1. Establish accountable care as foundational for reforming health care 2. Establish HIT as foundational for accountable care 3. Introduce the consensus developed publicly available ACO/HIT Framework 4. Suggest implementation approaches 5. Discuss the ACO Workgroup’s draft recommendations to the HIT Policy Council regarding how HHS can better support the accountable care environment
  • 3. Historical Silos: Fragmented Care Payer: Focus on Members Costs, and Measures • Contracts with multiple providers • Benefits vary per member • Available networks per member • Claims (what was paid for) • Diagnoses (on claims) • Clinical data extracted for quality measurement purposes (HEDIS) for NCQA, PQRI, etc.) • Emphasis on measurement Providers: Focused on the Patient and Internal Care Workflows • Reimbursed by multiple payers under multiple contractual arrangements • Cares for multiple patients with multiple benefit structures/networks • Cares for patients who see multiple other providers • Has information on care generated at point of care only Community Based Care: Focused on Individual Needs •Outcomes and goals •End of life wishes, living wills, etc. •Cultural preferences •Health risks •Public Health programs •Patient monitored data •Pastoral, social, familial caregiver supports •Independent of payer or provider
  • 4. The Goal of Health Reform Patient Focused Health & Care ProvidersPayers Community based care
  • 5. Basic Concepts: Patient Focused Care • Emphasis on preventive as well as acute care • Preventive care provided by teams • Patients included in the teams • Clinicians practice at top of their licenses • HIT must be able to support diverse information sharing across multiple constituencies • Data management/analysis foundational • Attention to social determinants of health • Focus on outcomes
  • 6. Getting There • Changing Roles and Responsibilities • Value based vs Volume Based Payment • Instantaneous availability of multiple types of Information
  • 7. Changing Roles and Responsibilities The Clinician of Record (legal responsibility) • Usually a primary care physician/clinician • Leads a primary care team that conducts follow up, monitoring, and supports preventive care in and out of office • Organizes and participates in a multi-specialty team if appropriate with patient The Specialist • Provides counsel and services as appropriate for care • Agrees to participate in patients’ team of care The Organization • Provides data management and analytical services • Provides access to needed clinical information (HIE, links, etc.) • Provides access to needed administrative information (networks, benefits, ADT feeds, etc.) • Contracts with aligned providers across the continuum of care
  • 8. Why Focus on HIT for ACOs? • Changing reimbursement policies: growing accountability for cost, quality, and patient focused care – Federal ACO/MSS rule – Commercial insurers offering multiple types of ACO models – Some states mandating accountable care from Medicaid providers – Over 500 providers groups in some form of financial risk arrangement • ACO payment different from HMO capitation of the 1990s – Emphasis on quality of care as well as patient engagement – No designated “gatekeepers” -- patients seek care where they wish – Care beyond the walls of the accountable provider(s) • Information needed to support these and changing roles
  • 9. Technology takes you beyond classic acute clinical care towards improved health outcomes •
  • 10. What is the ACO/HIT Framework • Consensus driven, publically available set of processes, functions, and HIT capabilities to support transitions to and through the ACO environment • “Glide Path” for providers taking on greater financial risk • Tool to assess readiness for assuming risk for costs, quality, and patient loyalty • Discussion platform within an institution, among institutions, for public policy
  • 11. The Framework Part 1: Summary • Represents a provider orientation -- how care delivery functions at the organizational level • Grounded in goals and objectives of care delivery • Process oriented in the accountable care delivery environment with necessary functions outlined for each process • Recognizes the importance of partnering with payers, other providers, community based organizations, and patients in achieving the goals and objectives accountable care.
  • 12. Important Consideration • Emphasis on Primary HIT requirements common to all organizations in the accountable care arena and to all processes – Sharing of health information – among providers internal and external to organization as well as with patients and their designated caregivers – Data integration from multiple sources -- clinical, operational, financial and patient derived – Specific patient safety features – Strong privacy and security protections • Can be implemented in multiple ways • Can be implemented by different partners
  • 13. The Framework Part 2: HIT Capabilities • Each process and its functions are defined in detail • HIT capabilities optimally supporting each of the 64 discrete functions are outlined • Patient safety features are bolded • MU 2014 criteria are starred
  • 14. Care Coordination Care Coordination involves two different but related aspects of patient care. One provides information to the clinician who must be able to access from and provide relevant clinical data to multiple sources in order to determine and provide for appropriate next steps in diagnosis or treatment. The other is to assure that patients are in the appropriate setting as they transition among multiple levels of care. Both are important for providing high quality care as well as mitigating excess, both must incorporate patient needs and preferences, and both are highly dependent on the ability to quickly and easily send and query health information on a given patient to and from multiple electronic sources.
  • 15. Framework Goal: Help Develop your own ACO/HIT Glide Path aligned with your Goals Focus Current Situation Transitioning Environment Transformed Future Clinical Culture Physician centric, individualistic, authoritative Primary care based teams, may include patient and designees True collaboration with all providers, patients and designees Cost Efficiency Cost measurement based on silos of payer claims Care coordination and care management processes Strong business analytics, contracts and improved clinical processes Reimbursement Incentive Mostly FFS, moving into upside financial risk Significant up and downside risk Most patients under global payment arrangements Patient Involvement Patient satisfaction surveys (to the patient) Patient outreach and follow up (for the patient) Patient as partners (with the patient) Quality of Care Reporting on a myriad of measures to a myriad of entities Manage specific cohorts to individual goals CQI based care process reengineering
  • 16. Major Challenges Many provider groups simply not ready – Insufficient capital – Governance – Inadequate HIT systems – No opportunity for a PCMH base – Lack of BH integration – Not enough patients in risk contract Payers not aligned – Different contracting arrangements – Different performance metrics and contracting arrangements – Different attribution algorithms – Different types of partnerships
  • 17. Major Challenges No access to available administrative data – Full set of claims (total costs of care, financial management) – ADT feeds – Social determinants of health – Real time Eligibility and Benefit information Inability to exchange clinical data and information – Within ACO environment – External to ACO environment – Telehealth – Remote monitoring devices
  • 18. • Decrease total costs of care: hospital admissions, readmissions, and ER visits • Improve your quality metrics: focus on specified patient cohorts • Improve patient satisfaction measures: engage your cohort patients as much as possible, focus on outcomes Initiate HIT Supported, Patient Based Population Health Management: aka Cohort Management Getting Started: Low Hanging Fruit
  • 19. Critical Components of Cohort Management 1. ID patients and cohort(s) (data and analytics) • Predictive modeling for high cost patients (need all claims, patient supplied, and clinical data) • ID by procedures, dx, gender, age, meds, etc. 2. Prioritize your cohorts (data and analytics) • Opportunities to decrease cost • Opportunities to improve quality metrics • The Scope/Resources/Time Triangle • ROI analyses
  • 20. Critical Components 3. CDS – HIT system support • non intrusive, usable for clinician AND patient • appropriate to cohort • reliable, valid, accurate 4. Ability to monitor and flag events and results – HIT system support • Access to ADT feeds • Specified milestones and goals • Trending capabilities • Applicable to all patients in a specified cohort
  • 21. Critical Components 5. Patient Engagement – multiple HIT approaches • Culturally appropriate information and educational materials • Secure messaging, texting, etc. • Capture data from remote monitoring devices • Patient/caregiver access to own data and records • Participation in team assessments and planning 6. Preferred Provider Engagement-referral network • Include community based services • Include all relevant specialties on team (BH)
  • 22. Critical Components 7. Shared Careplans -- HIT system support • Accessible by all providers as well as patient/caregiver, including hospital staff as needed • Includes patient specified goals and objectives • Includes information on HC proxy and/or MOLST 8. Appropriate Interventions – HIT system support • CPOE, ROE • Access to up to date clinical reviews • Incorporation of patient preferences • Scheduling on behalf of the patient
  • 23. Critical Components 9. Follow up – HIT System Support • Record all results • Notify clinician if appointment, test, procedure, medication not obtained or kept • Update careplans and monitoring applications • Communicate with patient 10. Monitor the Cohort – Data Analytics • Quality indicator goals being met • Savings accrued • Patient satisfaction • Program costs
  • 24. Attend to your Drivers • Payment reform at all levels (clinicians) • Robust Health Information Exchange • Data access (claims, clinical, administrative, patient reported, data on social determinants), integration, analysis (monitor, predict, plan) • Programs and processes for patient management outside of the traditional delivery system • Culture change -- at all levels
  • 25. Culture Change: Early Goals Ambulatory Care  Minimize Administrative Burden  Establish Patient Centered Medical Homes  Integrate BH (MH and SA) and Primary Care Hospital:  Minimize administrative burden  Establish multi-disciplinary care teams  Extend discharge planning through next encounter
  • 26. Five Components of Culture Change • Simplify -- minimize clinicians’ administrative burden, do not add to it; make it easy for patients to navigate your website, your campus, and their specific encounters • Inform – make it easy for clinicians and patients to find valid and reliable information when they are looking for it (up to date topic specific monographs); provide important information (PH alerts, drug recalls, relevant clinical trials) on a regular basis • Educate – using culturally appropriate methodology for patients and non intrusive, informative, up to date CDS for clinicians • Communicate -- secure messaging, texting, shared EHR • Collaborate – incorporate patient (their designated caregivers) and all members of their care team in relevant discussions and decisions; create shared understanding of treatment goals and revisit them frequently.
  • 27. Sharing Clinical Information: Early Goals • Coordination of Care at the Primary Care level • Safe handoffs during transitions of care • Medication Reconciliation in both inpatient and outpatient settings
  • 28. Sharing Clinical Information Within an accountable care organization  Same EHR, same implementation  Cross-viewing  Portal technology and a Clinical Data Warehouse  Community Based HIE With external providers  Community Based HIE  Cross-viewing  LAND and SEE technology With patients  Patient portals  Secure messaging  Texting  Remote monitoring devices
  • 29. Data Access: Early Goals • Compute total costs of care for attributed patients, track financials • Predictive modeling (ID cohort appropriate patients) • Track quality measurements • Know when and where your patients are getting their care
  • 30. Data Access Create a data warehouse (quality reporting, basic analytics, predictive modeling) Negotiate with payers (APCD if you have one) • Total claims data on your attributed patients (total costs of care) • Eligibility and benefit feeds from payers (networks, co- pays, deductibles, etc.) Negotiate with other providers/HIE • ADT feeds • Use of a shared care plan
  • 31. Data Access, Integration, Analysis Claims -- All payer data bases (including BH)  Total costs of care, program evaluation, risk sharing algorithms  Business Intelligence Analyses – Descriptive – reports, dashboards, trends, monitoring, etc. – Predictive – applied statistics and modeling to identify priorities – Prescriptive – linear programming and regressions to analyze options  Attribution algorithms, leakage, alternative payment methods Social Determinants of Health  Data from multiple state agencies and departments Community based programming  Population needs assessments  Program development and assessment  Patient derived outcomes data
  • 32. Payment Reform: Early Goals Only take on financial risk than you can handle • Upside risk only (MSSP, PCMH bonus, P4P) • Up and down side risk -- if you can do it for about 30% of your patient population • Global budgets, capitation, bundled payments -- not until you’ve proven successful in less risky contracts Consider other than FFS/productivity remuneration for clinicians, especially specialists Include care outside of the office setting in remuneration formulae
  • 33. The ACO Workgroup • Reports into the Federal HIT Policy Committee to HHS • Meetings based on ACO/HIT Framework June- November • Public Testimony: December 5, 20113 • Recommendations due Q1 2014 • Objective: How can HHS (writ large) policies and programs better support innovative approaches in the AC environment, particularly with respect to HIT?
  • 34. Recommendations in Discussion: CMS Support to Adopt Robust HIT • Increase up front funding for MSSP or funding for including partners not eligible for MU • Require 50% of PCPS to have met at least MU stage 1, particularly for two sided risk • Require plan to integrate BH and physical health, using HIT • Require “Glide Path” Plan • Require commitment from external care partners to share clinical information electronically on mutual patients
  • 35. Recommendations in Discussion: Access to Administrative Data Claims • Support APCDs in every state through the SIM grant mechanism • Release Medicare BH claims data • Release Medicare claims data to potential MSSP applicants • Explore how to integrate with clinical data • Encounter data • HL7 standards and scalable architecture for ADT notifications to ACOs SDH • Convene PH stakeholders to develop SDH markers for accountable care • Support intra-state collaboration among multiple agencies and departments Eligibility and Benefits • Make Medicare and Medicaid E and B data available 24/7 to guide cost effective, patient centered referrals for care. Encourage commercial insurers to do the same.
  • 36. Recommendations in Discussion: Sharing Clinical Information Policy and Strategy • SAMHSA to issue guidelines to clarify issues re sharing BH data and work with OCR, CMS, and ONC to modify CFR 42 if necessary to optimize care • CMS to use survey and cert program to review timely transfer of data to care partners • HHS to create a suitable measure for institutions sharing data and report on Compare Website • HHS to seek ways to mitigate difficulties with institutions not willing to share clinical data • Strengthen measures around cross vender exchange for future MU stages • Federal ACOs must participate in local/regional/state HIE if available Technology (Data Liquidity) • More specificity for interoperability standards for data beyond currently required • Develop a common API for HIT applications to allow real time data sharing • Develop and promulgate a voluntary testing and certification program limited to interoperability for all types of HIT • Retract ONC Certification of vendors who do not implement HIE capacity in the provider setting
  • 37. Recommendations in Discussion: Use of Data • Accelerate progress toward a universal approach to shared care plans (and make use part of future stage of MU? through testing of pilots • Bring transparency to the operative characteristics of predictive modeling tools to identify high risk patients • Develop a standardized algorithm for determining attribution and encourage its use by all payers • Measure effectiveness of CDS for improvement purposes • Integrate data from multiple sources to increase sensitivity and specificity in triggering CDS alerts
  • 38. Recommendations in Discussion: Administrative Simplification Streamline quality reporting • Align all HHS agencies and departments with respect to quality metrics • Lead commercial payers to align measure with HHS • Create a single quality measure repository that reflects all payers’ measures • Assure that all measures can be calculated from existing electronic data • Integrate claims and clinical data HIT Standards for Administrative procedures (e.g., prior authorization, referrals, care necessity attestations) CMS to review burden and value of all documentation requirements
  • 39. Thank You! Access to the interactive CCHIT ACO HIT Framework with User’s Guide Contact: Karen Bell MD. MMS Former Chair, Certification Commission for HIT ACO Workgroup member (HIT Policy Committee) Director, JBS Center for Sustainable Health and Care 781-801-4145 (cell) 617-834-4213 (office)