This series of commentaries has attempted, early in Accountable Care Organization (ACO) development, to identify health information technology functionality and architecture to support their developing needs.
Part I discussed possibilities for data warehouses, analytics, and reporting systems as well as models for outsourcing analytics to other organizations and “the cloud”. Part II focused on ACO health information exchange to support advanced information access for providers and applications.
Both emphasized population data management and registry capabilities in Medical Home, ACO, and public health contexts. ACOs bring new provider-side responsibilities and in both pieces, I discussed provider-side views on information. In Part I it was the “view” of the health system looking at its data. In Part II it was the individual providers’ view of the clinical data of the organizations in the ACO.
Provider-supported patient view
The organizing principal for this final take is the patient’s IT view on the ACO and the need to bring together coordinated communications, health record, and care support services.
This patient view may include a provider-supported patient portal, patient mobile health tools, home monitoring systems, and communications tools that face the patient as they interact with providers, provider data, and the provision of care.
The degree to which ACOs can present an integrated view across services and providers will vary. The organizations closest to having this kind of simplicity and access for patients now are major health systems and plans that provide care. ACOs have been somewhat modeled after these types of organizations, and the degree to which they can match their integrated IT environments will be related to the ACO’s success.
The starting assumption, however, is that ACOs, as sometimes loose associations of community providers and hospitals will not, themselves, support significant IT infrastructure. Some may be dominated by organizations with well-coordinated internal infrastructure that will. But in general, HIT coordination will depend on the types of included organizations, the organizations’ existing infrastructure, and the ACO’s political maturity.
Outsourcing and cloud-based services may be a key strategy for ACOs that are not close to an integrated organizational picture but recognize the need to get there. We have previously discussed how important an integrated ACO enterprise data environment will be for analytics and information access. It will also be a key metric for patient value and outcomes.
A technical triple aim?
From the perspective of the patient, a lot of HIT falls flat because it tries to connect to care that is loosely organized and provider oriented. Patients want services that provide value to them regardless of whom they need to connect to and where they need to find the relevant data. Patients want easy access, easy communication with those involved in supporting their care, and the ability to trust that their interests are being looked after in data sharing. The evidence is that rather than managing their own records patients want the healthcare system to manage them in a trusted way.
It is not surprising that the portion of the PHR industry that is getting the most traction is provider-tethered PHRs as elements of provider-supported portals.
Tethered PHRs generally have the best and easiest access to patient data and services. They can provide additional high value services like secure patient-provider email, scheduling, and lab result access. These seem to be as least as strong drivers for patient engagement as traditional record retrieval.
If you add portal functions of prescription renewal, remote patient monitoring, prevention programs, disease management, and care plan interactions, there is a compelling accumulation of patient value. If that value is then associated with a single portal where they only need to understand and remember one access methodology, where they can access all of their different providers and data, and where they can schedule multiple providers as part of a plan of care, patient centricity comes into focus.
Simplicity helps minimize costs
For the patient, an integrated portal is an attractive simplification of the jumble they frequently face. For the ACO, minimizing complexity can help minimize data management and IT infrastructure costs and eases data continuity. There are growing demands for managing patient identities and system access, managing data for currency and reduced reconciliation of medication lists, problem lists and care plans. Support is also needed for gateway services and enterprise indices for data retrieval.
In general, these are fast growing demands for data and systems support so, like the cost of care, coordinated infrastructure will not reduce costs as they stand today, but can help bend the cost curve downward. In the end it will be harder and harder for small individual organizations to mount and maintain the data and technology platforms they will need. These patient services are central to medical homes and other coordinated care and there is leverage in the pressures of patient needs to change resistance to inter-organizational coordination.
Going mobile
Information mobility is broadly about having information where and when it is needed as per the analytic stores and information exchange discussed in Parts I and II of this series.
From patient, provider and population perspectives, ACOs will need to support retrievability and searchability of health record information, not just point-to-point exchange. As was learned in the Internet explosion, indexing and querying information helps mobilize data and advance access. ACOs will support patient data look-up and retrieval for in house provider, patient portal, and inter-ACO gateway needs.
Mobilizing information can also include the hot mHealth trends. Mobile platforms advance provider and patient-centered computing. They provide an omnipresent IT platform that interacts directly with the provider for decision support and with the patient for home consultation and monitoring.
Mobile tools, however, add pressures for virtualization of apps and data, press security needs for sensitive information, and add new application service providers to the existing jumble of local hospitals, providers and EHR service providers. Ideally, the concept of a single integrated patient “view” would extend seamlessly between a portal and the various mobile and home monitoring platforms. With app stores and remote service provision, however, there is more complexity with the new enthusiasm.
Change is in the Air
As with much of the Affordable Care Act, ACOs face an uphill political battle for deployment. Even with the national investment in EHRs, business drivers still dominate health IT decisions. While HITECH was supposed to set the stage for ACA, it is pretty clear that ACA and business changes are needed to drive HIT functions for quality management and efficient workflow to justify the investment.
And all of this comes when there are many other changes in process. Pay for performance, quality measurement, patient-centric care, population considerations, prevention and medical homes are proceeding at the same time that providers have to learn to embrace technology-based workflow rather than resist it. At the same time the technology is changing and becoming more mobile, more virtualized and even more pervasive. Working with change may be one of the only certain parts of the ACO HIT future.
