The goal of an accountable care organization is to improve the integration of care among providers. This integration could encompass a wide variety of provider types, such as physicians, nurse practitioners, hospitals and non-acute providers. Ultimately, this integration should result in care that is safer, more efficient, and of better service and higher quality.
The organization of ACOs will vary. In some cases the ACO will be led by an integrated medical group, but in other cases the ACO will be led by a health plan, a hospital or an integrated health system. The ACO provider members also may belong to one parent organization, such as an integrated health system.
And while the ACO provider members will, in most cases, be legally distinct organizations that are bound by contracts, ACOs will be diverse in composition, legal form and patients served. Patients may be organized by condition (diabetes, cancer or heart disease) or category (children and the underserved).
The Need for a Health Information Exchange
Despite this diversity of provider types, ACO members will have a common need to implement a health information exchange. This exchange must ensure the flow of data about patients and facilitate the exchange of:
- performance metrics, such as care cost and quality;
- patient events, such as a visit to the emergency room or a failure to show up for an appointment;
- patient status, as in a hospitalization in a member hospital with a specific discharge destination.
This health information exchange could be provided by a regional or state organization that facilitates it among all providers in a geographic area. However, this exchange is more likely to be provided by an organization focused on interoperability targeted to ACO participants.
Targeted interoperability is common in industries other than health care. A manufacturer will have a high level of interoperability with its critical suppliers, while a computer manufacturer may have supply chain product forecasting and design interoperability with the company that produces its core electronics. Extensive interoperability also may include the exchange of a wide range of data and applications shared between manufacturer and supplier, such as circuit-design software.
That same manufacturer may not have such a high level of interoperability with suppliers that provide less essential components or those that are easily replaceable. In these cases, integration may take the form of a website that lets suppliers know of its needs and supports supplier bids for business.
A health care provider will have variable interoperability needs with respect to its electronic health record, as well as variable needs for the integration of its care processes. When a provider is a member of an ACO, the interoperability needs will be great between it and the other members. For a hospital and a provider practice that only occasionally refers a patient for admission, the needs will be less.
Extensive interoperability will be targeted to other providers for which there is a great deal of patient sharing and a joint accountability for the care delivered.
A Foundation for Targeted Interoperability
Implementing and managing targeted interoperability in health care is complex and challenging. The ACO will need to address several challenges, including governance, standards and shared processes.
Governance. ACO members will need to make decisions regarding their shared information-technology infrastructure. For example, what data needs to be exchanged for the ACO to perform well? Does this data include patient no-show events? The shared infrastructure may involve more than connecting several EHRs. Should members share internal phone and e-mail directories with each other? Should they use a common application for such functions as case management?
Identifying the boundaries of the shared infrastructure will require decisions regarding capital and operating budgets for the shared infrastructure, reporting relationships of the IT staff who manage this infrastructure, the allocation of IT costs among members.
Standards. While the federal government has established an initial set of standards to support health information exchanges, ACO members may decide to exchange data for which there are no national standards. What standard should they use in this case? Organizations in other industries have developed their own standards, accepting that these standards might not be used outside of their targeted exchange and one day might be replaced by national standards.
Shared processes. Targeted interoperability might start as a discussion about connecting EHRs, but it will move quickly to a discussion about shared or consistent processes. Consistent processes can take the form of common clinical decision support and common workflow engine logic among all participants, even if that support and logic need to be implemented in different EHRs. Consistent processes also can take the form of a jointly defined approach to patient education.
Shared processes could include case management, business analytics, clinical trials recruitment and shared laboratory testing facilities. ACO members will decide to share processes when sharing reduces the costs of providing care and improves quality. While ACO members will share processes to improve performance, they need to be mindful that extensive sharing can make it difficult to exit an ACO or to remove an underperforming member, due to high switching costs.
Almost any process that is shared or consistent will require an IT foundation to support that process.
Differing Levels of Information Exchange
Over time, ACO members will use two overall categories of health information exchanges: an extensive exchange among themselves, and a limited exchange with providers for which there is modest patient sharing.
However, the type of exchange necessary may not be so clear-cut. Two providers may not belong to the same ACO, but may engage in more than modest patient sharing. They may decide to implement some, but not all, aspects of the extensive ACO exchange infrastructure. For example, they may decide to exchange diverse types of data but not processes.
The ACO exchange capabilities are a portfolio of targeted interoperability capabilities. This portfolio includes elements that may be used in some cases, but not others—and within which some set of elements will be used outside of the ACO with one provider. A different set will be used with another provider.
The broad adoption of health information exchanges in the United States will be facilitated by the formation of accountable care organizations. However, ACOs will require an extensive exchange that will be more diverse and complex than the movement of clinical data from one provider to another—an exchange that involves diverse data and shared processes.
John Glaser, Ph.D., is the CEO of Siemens Healthcare Health Services in Malvern, Pa. He is also a regular contributor to H&HN Daily.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.