To remain competitive in a value-based care environment, health plans and ACO population managers must have visibility across a wide variety of care delivery settings. And, to effectively provide care for large populations, reduce the cost of that care and appropriately manage the risk associated with those patients, information must be captured from all caregivers, including ancillary providers such as rehabilitation specialists and mental health practitioners.
Today, most clinical data exchange takes a provider-centric approach, simply linking patient information gathered by a provider in a specific healthcare setting. While this method of exchange can enable more informed care for individual patients, its value for managing populations of patients can be more limited.
A move toward a member-centric approach to information exchange requires the capture of patient information for all members of a population regardless of the care delivery setting. It starts with the organization responsible for the care management of the population, such as a health plan or Accountable Care Organization (ACO). Working from member lists, care managers can access information available from the electronic health records (EHRs) in their provider network or from existing community or private health information exchanges (HIEs). Robust information from the health plan combined with the more granular clinical data from the EHRs translates to more effective management of broad patient populations--and thus benefits for all stakeholders.
In order to achieve this more comprehensive data sharing, however, health plans and provider organizations need to understand the emerging standards for data sharing and aggregation, as well as the financial incentives that support a member-centric approach.
Limitations of provider-centric HIE
Half of all hospitals in the United States had joined a private, state, or regional HIE as of 2012, according to research and consulting firm CapSite. The firm also notes that 71 percent of hospitals plan to purchase HIE solutions in the next two years.
While this growing acceptance is encouraging, a provider-centric approach to HIE only captures information for the members within these care settings. And, even if half to three-quarters of all hospitals are connected to an HIE, millions of patients whose providers have not signed on will still be missing from the database. In addition, the viability of publicly sponsored HIE initiatives is questionable as some have already failed and many more are struggling to find sustainable business models.
Furthermore, a provider-centric approach typically only provides visibility to care sought inside traditional locations, such as a patient's primary care practice or health system. This may be problematic given that research from PwC's Health Research Institute shows that only half of consumers say they would always stay with a hospital or group of physicians responsible for their care. With greater health system competition for complex surgeries and conditions, patients will continue to seek care outside their ACOs, especially in an era of increased consumer price transparency.
Thus, those who manage patient populations are left with incomplete information, especially when it comes to care management initiatives and prospective and retrospective analytics and reporting.
Seeing the entire picture
A more complete picture of patient populations requires health plans to work together with their provider networks to implement information technology solutions that support analytical tools and fill data gaps for both stakeholders. Health plans, for example, typically have claims and eligibility transaction data that indicate locations of care as well as diagnoses, but they may not always have a way to access additional clinical information from these providers. Likewise, even with access to more granular clinical data locally, providers may not be aware of care sought from unaffiliated providers.
No matter the technology chosen, a population health approach to information sharing will only work effectively if the tools efficiently and securely transport clinical information from a broad geographic footprint.
Standards emerging
Most within healthcare accept that standards are necessary before disparate organizations can begin to exchange clinical information. Many health plans and providers have grown to accept the more common HL7 and CCD standards because of their role in the Centers for Medicare and Medicaid Services (CMS) Meaningful Use initiative. The real foundation for "pushing" and "pulling" clinical information from EHRs, however, comes from a lesser-known body called Integrating the Healthcare Enterprise (IHE), which has created the Cross-Enterprise Document Sharing (XDS) and Cross-Community Access (XCA) standards.
XDS facilitates the registration, distribution and access of patient electronic health records across health enterprises, whereas XCA supports broader exchange by allowing queries and retrievals of patient-relevant medical data held by other entities. Yet another standard, DIRECT messaging, developed in partnership with the Office of the National Coordinator for Health IT, is a form of secure email that can play a role in moving information between health plans and providers.
Building bridges
Widespread multi-stakeholder collaboration is likely to be successful only with appropriate financial drivers in place. Most effective information sharing approaches leverage some type of shared risk contract within an ACO and/or ACO-like arrangement because they require a level of cooperation between health plans and providers to take care of their respective populations cost effectively. With common clinical and financial goals, the willingness to share data markedly increases on both sides. Among health plans, providers, and patients there is no shortage of data available to help effectively manage care. The challenge is aggregating all this data to provide meaningful information about the health needs and care of the population as a whole.
In order to achieve a truly member-centric approach to information sharing, health plans need technology built on recognized data standards that allow them to capture data on their total membership and ensure that high-cost patients are well represented. Platforms should enable analytical tools that alert population managers and providers to gaps in care and opportunities for clinical intervention. They should also allow health plans to query for data based on events such as eligibility or preauthorization transactions and claims submissions.
It will be to the mutual benefit of both payers and providers when comprehensive, aggregated patient health information becomes the basis for care management. And only then will truly collaborative activities set the stage for high quality and cost-effective healthcare delivery.