Entering into an ACO? Here are the tech tools to make it work.
If you're like a growing number of physicians, you've either considered joining an accountable care organization (ACO), or are quite curious whether an ACO will reap benefits for your practice. But achieving success as an ACO partner requires linking your data to the larger ACO community and then tapping into a host of technology tools that will help you communicate and collaborate effectively. And an EHR only scratches the surface of a practice's technology needs.
"An ACO is basically extending that medical home and integrating it further into the healthcare delivery system," says family physician Christopher Crow, cofounder of Village Health Partners, a medical practice with two locations in Plano, Texas, who is in the beginning stages of forming a regional physician-led ACO. "A practice's EHR is just a piece of a larger puzzle when you're thinking of the information and communication systems you'll need."
In order to facilitate collaboration across practices, Crow helped build a data warehouse system that links to and connects individual members' EHRs, creating a common data pool and communication platform that allows for coordination of care across settings. The system is equipped with population-health software that helps physicians manage patient populations by, for example, generating reports on high-risk individuals.
Other ACO models use health information exchanges (HIEs) to share data or common technology platforms dictated by large organizations leading ACOs.
The following are some essential tech tools to consider when you're starting out as an ACO.
Linking to the ACO data pool: HIEs
Robert Wergin, a family physician based in rural Nebraska, helped launch a Medicare Shared Savings Program ACO last year with 49 physicians in nine small practices. While all of the practices had EHRs in place, they were using a total of six different systems. "Coordinating and reporting the quality measures is more difficult if you have different systems that don't communicate very well," says Wergin, president-elect of the American Academy of Family Physicians (AAFP). The group must report on 33 different quality measures in order to participate in any shared savings. To address the problem, the group is considering joining an HIE, a secure electronic network funded by government grants or membership fees that allows members to access and share clinical data. According to a recent report by the Harvard School of Public Health, 10 percent of U.S. ambulatory practices were participating in 119 HIEs across the country in 2012, up from just 3 percent in 2010.
In Northeastern Oklahoma, MyHealth Access Network, a nonprofit community HIE, supports a 68-practice group participating in the Medicare Comprehensive Primary Care Initiative. Similar to an ACO, the initiative offers participants the chance to share in Medicare savings that result from improved, coordinated care.
"We aggregate community-wide health data," says David C. Kendrick, CEO and founder of MyHealth, as well as a practicing internal medicine and pediatrics specialist. "The new ACO models depend on management of the whole person, not just those at one practice. That's the HIE environment - we can see full patient information from many sources."
Members pay a nominal monthly fee to gain access to the network where they can exchange data and take advantage of analytics and care-management tools, says Kendrick, who is also an associate professor of internal medicine and pediatrics and chair of the department of medical informatics at the University of Oklahoma's School of Community Medicine in Tulsa. For example, members have access to decision-support tools such as Archimedes IndiGO, which calculates a patient's risk scores for various adverse events or diseases and suggests appropriate medications or interventions.
One of the biggest advantages of joining an HIE such as MyHealth is linking to a secure provider portal where physicians can easily collaborate with each other and view individual and community-wide patient health data, says Kendrick. Whereas the physician's office EHR may be missing a mammogram report performed by a specialist or a test result from the hospital, for example, the HIE contains the complete records for all patients and allows users to generate customized reports, such as which patients were admitted to the ER overnight.
"By doing decision support at the community-wide level we have a better chance of incorporating the broadest picture of the patient's health," says Kendrick. "We have tools that parse through data and identify people overdue for things like mammograms or cholesterol screens. And we can use that data to calculate risk scores that physicians can discuss with the patient."
Yet many small practices are still unfamiliar with information exchanges or see them as having limited value to their practice, according to a February 2013 report on physician perceptions of HIEs commissioned by the Office of the National Coordinator for Health Information Technology (ONC).
In the report, based on a survey of 68 physicians from five states who participated in a series of focus groups, physicians in small practices reported using their EHRs for improving efficiency within their own offices but rarely for clinical information exchange. They viewed HIE as primarily important for communication with local hospitals and specialists whereas larger practices reported being engaged in data analytics, patient tracking, and gathering performance data.
"Physicians in small practices tend to take an incremental approach to HIE by adding components of HIE and interfaces one by one as convenient, necessary, and/or affordable (e.g., e-prescribing and lab exchange)," according to the survey. The authors recommend that small practices connect with their local Regional Extension Center, run by the ONC's Office of HIT, to get help with using HIEs to participate in ACOs.
"The extent to which physicians use their HIE capabilities and overcome challenges to doing so is centrally important to realizing the vision of nationwide information exchange," the survey authors wrote.
While the pace of EHR adoption steadily increased from 34 percent to 43.5 percent between 2011 and 2012, few physicians reported using population-management functions, according to a national survey published in Annals of Internal Medicine in June, based on 1,820 primary-care physicians. (AAFP's 2013 mid-year member census reported an EHR adoption rate of almost 70 percent among family physicians).
However, being able to perform tasks such as generating lists of patients by disease or test results, or those overdue for tests, is crucial for ACO success.
Many physicians surveyed said their current systems were difficult to use for such purposes. For example, of the 34 percent of respondents who had systems capable of generating lists of patients who were overdue for preventive care, tests, or appointments, almost 21 percent found it difficult or impossible to generate those lists.
"Most EHR systems aren't set up to do population management," says Joe Taylor, vice president of ACO practice at Malvern, Pa.-based FluidEdge Consulting. "When I'm looking at a system, I want it to be certified for Stages 1 and 2 of meaningful use. Physicians need to effectively show payers the value they're adding, demonstrate their results, and get appropriate compensation."
ACO practices need to start thinking of patient registries as points of care for managing chronic conditions and preventive strategies, as opposed to basic statistics on immunizations or cancer, says family medicine physician Jason Mitchell, director of the Center for Health Information Technology at the AAFP.
"The registry is a snapshot of where a patient is in regard to specific issues,” says Mitchell. "It's a mechanism where you can capture data that's important around quality measures and overall health, and it should feed back into the patient's record."
Being able to analyze populations of patients ultimately leads to better care for each individual patient, he adds.
"If you know that 77 percent of your hypertensive patients are under control, the next time you see a patient with high blood pressure you're going to be a bit more aggressive because you know what your overall population numbers are," he says. "And that's important because ACOs are going to be reimbursed around that."
Another key factor in effective ACO partnership is engaging patients in their own care. One way to do that is by communicating and exchanging information through Web-based patient portals.
"The portal is the new front door of your office," says Derek Kosiorek, a principal consultant with the Medical Group Management Association, who specializes in health IT. "A significant amount of your interactions with patients will shift to the portal because it's more efficient for the patient and the practice."
In a survey of care managers and providers performed by TCS Healthcare Technologies, 15 percent of respondents reported using portals to communicate with patients in 2012, up from 3 percent in 2010.
When asked how they are using portals to improve patient access, family physicians surveyed by AAFP (986 total respondents) cited e-prescribing (30 percent), scheduling appointments and sharing information (26 percent), and e-visits (13 percent), according to AAFP's Practice Profile Survey.
Portals facilitate greater efficiency by allowing patients to enter complaints into the system before a visit, for example, or print out a child’s immunization record.
"We've had a portal for nine years now, and it’s a great tool to share information between the practice and the patient," says Crow.
Telehealth and remote monitoring
According to the TCS survey, the low-tech phone call was by far the most common form of technology used by providers to monitor patients for things like medication adherence and chronic-disease management. However, newer remote-monitoring tools are on the rise, and experts say they will become commonplace as ACOs mature.
Devices that the patient can use at home and transmit data directly to the practice's EHR are especially useful for monitoring patients with chronic conditions such as diabetes, says Mitchell. Currently, patients typically record their daily blood pressure and blood-sugar levels at home and report the numbers to their physician at regular office visits. It's good information but not easily filed or analyzed when presented on paper.
"If we can get that electronically uploaded in real time, the data can be presented in an easily understandable way," he says. "If a patient is having a failure in therapy, we can see it the week it happens instead of three months later at their next visit. Remote monitoring is really important for optimizing care and managing the information that's out there."
In the TCS survey, 28 percent of respondents said they used devices to monitor heart rate, blood pressure or other health statistics (compared with 64 percent who used phone calls). Others reported using lifestyle-monitoring devices, such as pedometers or meal trackers (19 percent); medication-reminder technology (19 percent); smartphone applications (8 percent); text messaging (8 percent); and video conferencing (3 percent).
To be cost-effective, remote monitoring should be focused on the patients who stand to benefit the most, says Taylor.
"Giving these devices to everyone is not really feasible and too expensive," he says. "You need to identify your high-alert patients that you really need to pay attention to - like those who just went into the hospital or had their blood sugar spike overnight - you don't need everything on every patient with a chronic disease, every day."
The ACO emphasis on preventive care and improved outcomes is driving greater interest in other telemedicine technology and virtual visits, which allow greater access to patients who cannot easily travel to physicians' offices.
"In some remote areas, people may have to drive 100 miles to see a mental health specialist," says AAFP’s Wergin. "Telemedicine portals give access to that care and that’s important to better outcomes."
Videoconferencing and electronic transmission of diagnostic images also foster collaboration among primary-care physicians and specialists within an ACO, says Mitchell. "You can link to a specialist in real time to get help, access a dermatologist to look at a spot you’re not sure about, or link a patient who is in your office to counseling services via a remote connection."
Mobile devices and apps
Another way to engage patients is through health-related applications for smartphones and other mobile devices. While there is a dizzying array of choices on the market, you can usually find a few that fit the needs of your patients, says Mitchell. To take one example, the Fitbit app wirelessly syncs statistics to iPhones, making it easier to track your fitness goals and keep track of calorie intake, he says. Smart watches and other wearable technology can also measure vital signs, such as heart rate and blood pressure, and eventually will transfer that data to the patient's EHR.
"We're going to see linkage of some of the hardware with the software tools that apps can provide," says Mitchell."The role of physicians will be to engage with patients to help them find the technologies that will provide effective self-management."
The type of patient-physician communication that is happening now via portals will eventually move completely to tablets and portable devices, predicts Crow."Patients will use multimedia to give information to the care team, much in the way you can look at an article online and immediately put it on Facebook or Twitter," says Crow. “In five years, a portal might be a bit archaic as we are able to communicate with mobile devices in a cloud-type platform."
If you're forming or joining an ACO, consider these essential tech tools:
• A health information exchange (HIE) is a secure electronic network that allows members to access and share clinical data.
• Devices that patients can use at home to transmit health data directly to the practice's EHR are useful for real-time monitoring.
• Patient portals encourage patients to engage in improving their own care.
• Population-management tools can help you generate lists of patients by disease or test results.
• Health-related applications for mobile devices also help to engage patients in their care.
Janet Colwell is a Brooklyn, N.Y.-based freelance writer specializing in healthcare. With more than 20 years experience as a journalist, she writes frequently about clinical and practice management issues for several national health industry publications. She can be reached at firstname.lastname@example.org