The CCHIT ACO HIT Framework A Guide to Success while Assuming Accountability for Cost, Quality, and Patient Engagement Karen M Bell, MD Chair, CCHIT 2013 Accountable Care HIT Strategies Summit September 10, 2013 San Francisco, CA
Why an ACO HIT Framework? Changing reimbursement policies encourage greater 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 More than 450 providers groups in some form of financial risk arrangement 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 Belief in the power of HIT to support new structures and processes Many new provider groups unclear about what they will need and where to start their HIT roadmaps No structured comprehensive public discussion at the implementation level 2013 Slide 2 September 10 2013
Value of the Framework Provider groups taking on financial risk -- self assessment and roadmap development, depending on organizational goals Payers -- assess readiness of proposed AC partners to take on risk; partnership opportunities Developers -- fill gaps Policy makers HITPC ACO WG recommendations All of us -- enhanced structured discussion and understanding of what it means to move along the continuum from current care to a transformed delivery system 2013 Slide 3 September 10 2013
Silos Preclude Person Focused Health and Care Payer Care: Focused on the Member (Employer) and Costs 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 Provider Based Care: Focused on the Patient and 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 Patient monitored data Pastoral, social, familial caregiver support Independent of payer or provider 2013 Slide 4 September 10 2013
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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 2013 Slide 6 September 10 2013
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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 2013 Slide 8 September 10 2013
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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 2013 Slide 10 September 10 2013
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. 2013 Slide 11 September 10 2013
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The Framework Part 3: An ACO HIT Glide Path Based on how the care environment will likely change as provider organizations become more and more accountable for quality, costs and customer loyalty Acknowledges accountable care as really about healthcare transformation Each organization will have a unique glide path, commensurate with its own short and long term goals Functions and HIT capabilities may be more limited in early stages of healthcare transformation and grow incrementally as needed 2013 Slide 13 September 10 2013
The Goal: Healthcare Transformation 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 2013 Slide 14 September 10 2013
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Financial Management: It s All About the Data Data sources - all payer data bases, consolidated clinical data from multiple EHRs, operational systems Business Intelligence Analyses Descriptive reports, dashboards, trends, etc. Predictive applied statistics and modeling Prescriptive linear programming and regressions to analyze options Revenue Cycle Management Book different types of reimbursements and their cycles Pay clinicians other than straight FFS Identify and plan for areas of loss Supplier management Other: attribution, leakage, program evaluation 2013 Slide 16 September 10 2013
Knowledge Management: With a Little Help From Your Friends CDS beyond alerts and reminders to clinicians Diagnostic and treatment options CDS to patients and designees Document management and search engines for advanced business analytics Personalized medicine Outcomes based on patient supplied data with respect to function, overall health and meeting of goals 2013 Slide 17 September 10 2013
Patient Engagement: Keep your Pasture Greener Simplify: easy to seek all care with or through you Educate: to the patient Communicate: for the patient including follow up and making appointments as in PCMHs Incorporate: with the patient including both their preferences and their advice 2013 Slide 18 September 10 2013
Clinician Engagement: Culture Eats Technology for Lunch Provide good data on practice and patients Administrative simplification Support for collaboration Supply or link to useful information Assessment tools Up to date clinical information programs Relevant payer, public health, research, community resources and cultural links 2013 Slide 19 September 10 2013
How to Use the ACO HIT Framework Step 1: Map short and long term goals and objectives to the broad areas on the Glide Path and corresponding processes and functions Step 2: Assume 2014 ONC Certified products; focus on Primary HIT Requirements Step 3: Conduct internal assessment of HIT capabilities that support the identified processes and functions that match your goals Step 4: Roadmap the gaps: functions first, then HIT support 2013 Slide 20 September 10 2013
The ACO Workgroup Reports into the HITPC Recommendations due end of December 2013 Initial focus on developing certification criteria for Meaningful Use Stage 3 Current direction Continued review of Framework elements Assessing what exists now in MU against ACO needs High priority interoperability standards Data integration policies to support business analytics Other Federal policy levers to support ACOs 2013 Slide 21 September 10 2013
The Goal of Health Reform Payers Patient Focused Health & Care Providers Community based care 2013 Slide 22 September 10 2013
Thank You! Access to the interactive CCHIT ACO HIT Framework with User s Guide www.cchit.org/hitframework We welcome general comments and feedback regarding either CCHIT s work or the ACO WG activity Contacts: kbell@cchit.org Karen Bell, Chair & ACO Workgroup sreber@cchit.org Sue Reber, Outreach Director 2013 Slide 23 September 10 2013