By Ben Chronister, VP and GM Platforms, Caradigm
Rapidly shifting payment models, from fee-for-service to value-based payments, are driving an increased demand for system interoperability. For example, care providers who are members of accountable care organizations (ACO), as defined in the Affordable Care Act, can potentially earn significant Medicare rewards for the realized cost savings from bundled payments and meeting pre-defined quality of care benchmarks. But without interoperability, it is extremely challenging to realize those cost savings or improve quality of care.
Likewise, one of the windfalls of value-based care models is that they are designed to increase productivity, avoid duplicate medical procedures, and achieve shared savings as a result of payment by episode of care (an episode payment is a payment for all services needed by a patient for all inpatient and follow up care involved after a major hospitalization event). But to effectively coordinate care, close gaps in care, and manage overall utilization, these models rely on high levels of coordination among providers, which can only be achieved via improved system interoperability.
As such, a broad range of health providers operating in population health environments today increasingly require better interoperability within their systems. So what would a world of increased interoperability look like and how would it differ from what is normally experienced today?
Typically, patients today are largely responsible for coordinating their own data sharing among health providers. This means they may even have to carry prescription bottles to a new doctor to complete their medication review. Even so, they may not know what data is relevant to the current situation, may not have access to all the relevant information, and might not be able to remember or keep track of what has occurred — especially if they are elderly or chronically ill. In addition, they may not know the reasons why a particular medication was prescribed or the overall treatment strategy.
Even when healthcare providers take responsibility for the information flow, they often rely on documents faxed to their offices. This leads to unstructured data in patient records or time-consuming data entry that is subject to error. In general, medical professionals do not have time to track down information and enter it into EHR systems manually, and their time is better spent diagnosing and treating patients rather than entering data.
Because of this, the demand for interoperability has reached a crescendo, as it is now a must-have in order to succeed with population health. It’s important to understand how care workflows can be transformed by interoperability because disparate information systems greatly hinder an organization’s ability to effectively coordinate care, close gaps in care and manage overall utilization.
Consider a scenario in which healthcare is better coordinated and made more efficient by the interoperability of disparate systems used by multiple clinicians. In this example, our patient visits the local emergency department because of dizziness and shortness of breath. She is treated in the Emergency Department for noncompliance of her diabetes mellitus treatment and is admitted to the hospital with a diagnosis of diabetic ketoacidosis. After a hospital stay, she visits her primary care physician (PCP), who enrolls her in a diabetes care management program and refers her to a cardiologist and ophthalmologist for further assessments.
Many of us know someone who has had a similar medical intervention and may have endured unnecessary repeated medical history questions and/or tests. But improved interoperability can transform care workflows. For example, here’s what is possible:
Once the patient is discharged from the hospital, her records are transferred electronically to her PCP’s EHR system. As is often the case, the hospital’s information system may be different from the PCP’s system.
After the office visit, her PCP determines that she would benefit from enrollment in a diabetes care management program. The PCP then creates a referral continuity of care document (CCD) for the care management team in her EHR system. But first, before any clinical document is shared, the system confirms that the patient’s consent to share data electronically is on record. The referral request is sent to the care manager via a secure email and triggers the assessment of the patient.
The care manager starts the enrollment process within the care management application. She is able to view the patient’s longitudinal record, which allows her to efficiently complete the enrollment process for the diabetes care management program.
The care manager reviews system-generated tasks including assessments and medication reviews, and generates recommendations for the patient’s plan of care based on assessment details. She produces a personalized plan of care for the patient and can opt to create a snapshot of the patient’s comprehensive plan of care for sharing with other members of the care team.
The care manager can send the comprehensive plan of care back to the PCP who initiated the referral via a HIPAA-compliant direct secure message.
Once the plan of care is registered in the document registry it is available to the PCP and other providers to ensure that all parties are aligned with the goals of the care plan, especially during care transitions.
The takeaway from this scenario should be that there exist better ways to share referral documents with patient’s longitudinal records and plan of care among all members of the care team, including the primary care physician, the care manager and providers from the hospital. This workflow can improve overall care coordination, increase productivity and ultimately improve patient outcomes.
And if you believe that this care workflow example demonstrates strong benefits, consider the value of interoperability in even more complex healthcare environments, such as ACOs, where additional coordination is required. With ACOs, multiple teams within the network all share joint risk if patients aren’t receiving proper treatment. This makes ACO members even more motivated to share information than in the past.
We’re moving quickly to value-based care models, making interoperability ever more important. Too often today we rely on patients or inefficient manual methods to communicate potentially critical health information. This approach is impractical and has not led to effective sharing of information. We now require an increased focus on care workflows based upon the application of interoperability technology. The differences can be transformational.