Patient Panel Analytics

In a recent interview with a provider about how to gain some efficiencies in her practice, I asked how many patients she was caring for with a diagnosis of cancer in the past few years. After a “from the hip” answer, I showed her a report from one of her payers, and she became frustrated that the payer had a better summary of her patients than she could obtain from her own EHR.

Healthcare providers and management need to be empowered with tools to analyze information about their practice in which much effort is spent creating the data.

This podcast will demonstrate our Accountable Care Analytics Application’s ability to define patient panels and provide integrated summaries of patient information from clinical and claims data sources.

Accountable Care Analytics: A data-driven approach to achieving value-based healthcare

Edgewater’s Accountable Care Analytics application is comprehensive set of data integration and business intelligence capabilities for use by clinical, financial, and care management professionals that empower organizations to improve quality and reduce costs across a spectrum of care delivery settings.  The application streamlines many of the labor-intensive aspects of capturing and reporting quality and financial performance of accountable care, alternative quality contract, and similar risk-based arrangements operating in healthcare today.  It achieves this by enabling healthcare providers to take a data-driven approach to understanding the impact of quality, cost and outcomes on performance across the extended ACO enterprise.

In this podcast, Edgewater provides a high level overview of the Accountable Care Analytics application.

ACO Disease Specific Analytics

“What can Edgewater’s Accountable Care Analytics do for me that we cannot already do with our EHR and patient financials reporting?”

To be successful, ACOs and other integrated health systems must bring together both clinical and claims data – and they must make the data available for use by clinical, operational and financial leadership across the entire organization.  The biggest challenge our clients face is an ability to provide management this data now, to drive early operational decisions. This is what Edgewater’s Accountable Care Analytics can do – provide organization-wide dashboards for decision support in advance of the complex and time consuming integration projects these health systems face.

This podcast shows a quick demonstration of the capabilities our ACA application.

Edgewater Healthcare Analytics

I recently read an article called “The 4 Biggest Obstacles ACOs Face” on Forbes.com that I found really interesting. In it, the author identifies what I think are the primary challenges for Accountable Care Organizations (ACO). But, I would change the order.

ACOs need a management structure in place to make critical operational decisions. But those decisions should be made leveraging enterprise wide data. So, the primary challenge for ACOs — Providing management with accurate, actionable data to make management decisions, before all of the technical integration challenges have been addressed.

To learn more about Edgewater’s Accountable Care Analytics application, and how it can help you get meaningful data to ACO decision makers, email us.

The Politics of Data in an ACO

Data sharingImagine the following scenario. You discover that you are the victim of identity theft, purchases have been made in your name, and your personal credit has been ruined. You are saved, though. You have paid a watchdog organization to monitor your credit, and they have information that clears your good name! So, when you apply for a loan with a bank, you request the credit monitoring agency to share the details of your prior credit problems and its resolution with the bank. But the monitoring agency will not share that information because that might help the bank understand your needs and negotiate a better price for their own credit monitoring service that they resell to their customers – i.e., you. The monitoring service won’t release your information.

Would you put up with this conflict of interest? NO!

In healthcare, we routinely tolerate a form of this conflict of interest, and in many different forms. Even though health insurers are not providing the patient care directly, these payers tend to accumulate a very useful holistic view of each patient’s history, including information from the perspective of what care was provided based on payment being demanded by many different care providers. There are numerous instances where, if this information was shared with other providers, it could positively impact the care management plan, doing so in a more timely manner, and increasing the likelihood of improving the quality of care the patient receives and possibly reducing the overall cost of care across an extended episode.

Here is an example- A patient is admitted to the hospital and receives a pacemaker to address his atrial fibrilation. After being discharged, the patient follows up with his cardiologist who has reduced the dose of digoxin, having diagnosed the patient with a digoxin toxicity. However, the patient attempts to save a few dollars by finishing their current prescription only to be admitted to the hospital a couple of weeks later for the toxicity. This is an opportunity where the care manager could have intervened based on the cardiologist’s toxicity diagnosis being submitted to the payer and no prescription was filled within a few days. The care manager could have helped the patient be more compliant with the cardiologist’s instructions avoiding an inpatient admission.

Healthcare provider organizations and payers (and in some cases regulators) are working together to break down these walls in an effort to increase value across the spectrum of care delivery and the industry in general. However, the sometimes conflicting vested interests of these interacting payers and providers can still be an obstacle, influencing the politics of information disclosure and sharing in the emerging environment of accountable care delivery models.

There is great diversity in the participating organizations that collaborate to make up an ACO. This is definitely not one size fits all. Viewed from the perspective of sharing risks across parties without the immediate concern about maximizing volumes, the integrated provider-based health plans, such as Kaiser Permanente, Geisinger Health System, and Presbyterian Healthcare Services, are already inherently sharing this risk and are reaping the rewards as a single organization. That’s great for the few organizations and patients that are already members participating in one of these plans.

Unfortunately, for other organizations there is still much more to be worked out regarding proactive sharing of data both within an accountable network of providers acting across care settings, and with the payer(s). Within the network, hospital systems usually have some of the infrastructure in place and they know how to routinely share data between systems and applications using standard data exchange conventions such as HL7 and CCD. In collaboration with HIE’s these systems can help facilitate active data distribution, and they very often provoke the organization to address some of the more common aspects of data governance. However, even when this routine “transactional” and operational data is being exchanged and coordinated, there is still a great unmet need for the ACO to buy or build a data repository for the integration and consumption of this data to support reporting and analytics across various functional areas.

Many organizations encounter further challenges in defining and agreeing on which are the authoritative sources of specific elements of data, what are the rights and limits on the use of these data, and how can these assets be used most effectively to facilitate the diverse objectives of this still-emerging new organizational model.

An even greater challenge for some ACOs is collecting the required data from the smaller participating provider networks. These organizations often have less capability to customize their EHRs (if they even have EHRs in place) and less resource capacity to enable the data sharing that is required. To get around this, some ACOs are:

  • Standardizing on a small number of EHRs- (ideally one, but not always possible) This provides the potential to increase economies of scale and leverage the shared learnings across the extended organization.
  • Manually collecting data in registries– Although not always timely, this addresses some rudimentary needs for population-focused care delivery and serves to overcome common barriers such as the willingness of a given provider to collect additional required data and complying with standards.
  • Not collecting desired data at all– While this seems hazardous, progress toward the overall clinical and/or financial goals of the ACO can still be positive, even if an organization cannot directly attribute credit for beneficial outcomes or improvements within the organization, and the ACO can avoid the overhead of collecting and manually managing that data.

Regardless of what data is collected and shared within the ACO, the payers participating often have the highest quality, most broadly useful longitudinal data because:

  1. The data is ‘omniscient’ – it represents, in most cases, all of the services received by (or at least paid for) that patient – provided a claim for those services has been submitted and paid by the participating payer.
  2. Some of this data is standardized and consolidated making it easier to manage.
  3. The data is often enriched with additional data residing in mature information systems such as risk models, and various disease-focused or geographic populations and segments.

Consequently, payer data very often forms the longitudinal backbone that most consistently extends across the various episodes constituting a patient’s medical history and is very important to the success of the ACO’s mission to drive up quality and drive down costs. Despite this opportunity for an ACO to improve its delivery of care to targeted populations, sharing of data is still achieved unevenly across these organizations because some payers feel the utilization, cost and performance data they have could be used to negatively impact their position and weaken their negotiations with the hospitals and other provider organizations.

While claims have traditionally been the de facto standard and basis for many of the risk and performance measures of the ACO, more progressive payers are also now sharing timely data pertaining to services received outside the provider network, referrals between and among providers, authorizations for services, and discharges, further enabling ACOs to utilize this information proactively to implement and measure various improvements in care management across the spectrum of care settings visited by patients under their care.

Collaboration between provider organizations and payers at a data level is moving in a positive direction because of the effort given to ACO development. These efforts should continue to be encouraged so as to realize the possibilities of leveraging timely distribution of data for better treatment of patients and healthcare cost management.

Are you “ACO IT-Ready”?

First things first, I believe the push for accountable care is here to stay. I do not think that it is a fad that will come and go as many other attempts at healthcare reform have. Having said that, I also strongly believe that very few organizations are positioned to start realizing the benefits that will come from this reform any time soon. It’s not for lack of trying, as many organizations are already recognized as Pioneer ACO’s. But the hard part is not being established as an ACO – it’s proving you’re reducing costs and improving quality for targeted patient populations.

The first step will being January 1st, 2013. Some ACO’s will be required to start reporting quality measures – for instance the Shared Savings program from CMS for both the one-sided and two-sided models require reporting 33 quality measures. Notice I said “reporting”. So for the first year, it’s “pay for reporting”. Years 2 and 3 is when the rubber really meets the road and it becomes “pay for performance”. “Don’t just show me you are trying to reduce costs and improve quality, actually reduce and improve or realize the consequences.“

With ACO’s come reporting requirements. We in healthcare are used to reporting requirements. And those of us willing to publicly acknowledge it, more reporting means more waste. Why? Because there is job security in paying people to run around and find data…and to eventually do very little with it other than plug it in a spreadsheet, post it to a SharePoint site, email it to someone else, or well, you get my drift. Regardless of your view on these new requirements, they’re here to stay. So the $64,000 question is, are you ready to start reporting?

There is a wide range of both functional and technical requirements that healthcare providers and payers will need to address as they start operating as an ACO.  Many of the early and emerging ACOs have started the journey from a baseline of targeted patient panels to the optimized management of a population, progressing through a model with some or all of the following:

These are 7 simple questions you must be able to answer and report on DAY 1:

  1. Can you define and identify your targeted patient populations?
  2. Are you able to measure the financial and quality performance and risks of these patient panels and populations?
    1. Can you quickly, easily and consistently report quality and financial measures by Physician, Location, Service, or Diagnosis?
  3. Can you baseline your expenditures and costsassociated with various targeted patient populations?
    1. How will you benchmark your “before ACO” and “after ACO” costs?
  4. Can you accurately monitor the participation, performance and accountability of the ACO participants involved in coordinated, collaborative patient care?
  5. Will you be able to pinpoint where and when the quality of care begins to drift, so as to quickly intervene with care redesign improvements to limit the impacts on patients and non-reimbursable costs?
    1. Are you able to detect “patient leakage and provide your organization the information for its’ management? (Patient leakage is when a patient that you are treating as an ACO for a bundled payment, leaves the network for their care)
      1. Is a particular provider/provider group sending patients outside of the ACO?  If so, is it for a justified reason?
      2. Does the hospital need to address a capacity issue?
  6. Can you reconcile your internal costs of care with bundled reimbursements from payers?
  7. Are you positioned for population health management and achieving the Triple Aim on a continuing basis?

In order to answer these questions you must have a highly integrated data infrastructure. It seems I’m not the only one who agrees with this tactical first step:

  • The Cleveland Clinic Journal of Medicine agreed as it listed as one of its’ 5 Core Competencies Required to be an ACO “Technical and informatics support to manage individual and population data.”
  • Presbyterian Healthcare Services (PHS) has been a Pioneer ACO for over a year. Tracy Brewer, the lead project manager was recently asked by Becker’s Hospital Review, “What goals did you set as an ACO in the beginning of the year and how have you worked to achieve them” and her answer – “One of the major ones [goals] was updating our administrative and IT infrastructure. We had to make sure we had all the operational pieces in place to function as ACO. We also completed some work on our IT infrastructure so that once we received the claims data from CMS, we could begin analysis and really get value from it.”

The ACO quality measures require data from a number of different data sources. Be honest with me and yourselves, how confident are you that your organization is ready? Is your data integrated? Do you have consistent definitions for Providers, Patients, Diagnosis, Procedure, and Service? If you do, great you don’t have much company. If you don’t, rest assured there are organizations that have been doing data integration for nearly two decades that can help you answer the questions above as well as many more related to this new thing they call Accountable Care.

So You Think an Accountable Care Organization (ACO) is a Good Idea – First Things First, What’s your Data Look Like?

I will not pretend to know more about Accountable Care Organizations (ACOs) than Dr. Elliot Fisher of Dartmouth Medical School who is the unofficial founder of the ideas behind this new model for healthcare reform. But if I may, I’d like to leverage some of his ideas to outline the necessary first step for creating a new ACO or being included in one of the many that already exist.

First and foremost, I understand that there are very smart people out there who insist ACOs are a bad idea (click here and here to read strong arguments against ACOs). Having said that, there are fundamental aspects of ACOs that are prerequisites for success; one of these is the ability to calculate mandated performance metrics and share this data electronically with other members of the ACO. How else are they going to know if it’s working (and by working I mean lowering costs while improving the quality of care)?

Healthcare providers are used to having to calculate quality metrics, like Core Measures amongst others, for the purposes of demonstrating high quality care, being compliant with regulator mandates, and satisfying their patient populations. What they’re not used to is having to report in a timely fashion. Hospitals routinely, for instance, report CMS core measures months after the patient encounters actually occurred. The previous 3 clients I worked with reported March/April/May measures in August. The Senate Bill that allows for CMS to contract with ACOs specifies the need to share performance metrics among participating entities but leaves the how and how often to each ACO to decide. This could be extremely problematic considering the huge discrepancy across our provider networks of the necessary healthcare IT infrastructure to gather, calculate, and report these metrics across care settings in a timely manner.

The first thing to consider when contemplating participation in an ACO is, “How robust is your data infrastructure and can you meet the reporting requirements mandated for any ACO participation?” Dr. Fisher points out, “We have been collaborating withCMS, private health plans, and medical systems to identify and support the technical infrastructure needed to deliver timely, consistent performance information to ACOs and other providers.” If you think your paper-chasing and manual chart abstraction that gets you by today for most reporting requirements will fly, think again. An ACO will only be as strong as its weakest link. A successful ACO is able to monitor its progress against the benchmarks established for total cost for delivering healthcare services per enrollee. The overall goal is to lower the cost to provide services while maintaining a high level of quality, and subsequently share the cost savings. There are other similar models such as the Alternative Quality Contracts (AQCs) currently rolled out by BCBSMA, with similar criteria and financial incentives. In both cases, though, the fundamental data infrastructure is required to meet the stringent reporting requirements. In addition, as ACOs gain traction and identify new ways to lower the cost of providing care, the need for a robust reporting infrastructure to eliminate the tremendous amount of time and money spent on collecting, calculating, reporting and distributing information including quality, operational, clinical, and financial metrics becomes even more instrumental.  The best case scenario also includes an evolution to healthcare analytics when analysis of data spans care settings, siloed applications, and even facilities (Chet Speed, the American Medical Group Associations VP, Public Policy agreed with me on this point in his recent interview with Healthcare Informatics). But first things first.

You can do a lot to improve your chances of success within an ACO; start with understanding the requirements for sharing discrete, accurate, consistent data, it’s a great first step. Good luck!