When Donald Berwick and the Institute for Healthcare Improvement launched the Triple Aim initiative in 2008, they envisioned a framework for optimizing health system performance by simultaneously focusing on the health of a population, the experience of care for individuals within that population, and the per capita cost of providing that care.
Two of the three preconditions they cited for this to succeed were the enrollment of an identified population and the existence of an organization that accepts responsibility for all three aims for that population. [Health Affairs, May 2008] Hospital executives will tell you that, in order to enroll a population of patients and be accountable in this way, the “integrator,” as the IHI called it, must control a quality-driven provider network connected by a sophisticated health IT platform.
Relative to building a health IT infrastructure, putting together a provider network is relatively simple. Narrow provider networks have the same purpose in healthcare as narrow supplier networks have in every other industry – value is created by selecting the low-cost providers that meet quality standards.
Narrow networks existed long before the 2010 Affordable Care Act (“ACA”), which called for Accountable Care Organizations (“ACOs”), bundled payments, medical homes, and value-based purchasing. They were developed in the 1990s by insurance companies and large employers to control healthcare costs. Twenty years ago, narrow networks failed to deliver for two major reasons – a lack of economic incentives and poor IT infrastructure.
Today, bolstered by sweeping healthcare payment reform that includes incentives for adopting and using technology, hospitals and health systems are aggressively developing narrow networks to serve as ACOs – and they are betting big on health IT advances.
Most industry experts agree that, in addition to the role of ACOs, the widespread adoption of health IT capabilities will be vital to achieving the quality and cost objectives of the ACA. The chief health IT constraint today is the usability of EHRs. While there are success stories, EHR adoption rates have been slower than expected because of poor usability.
The usability of EHR systems has not received the same level of attention as software features, functions and technical requirements. As a result, many clinicians and the American Medical Association are calling for an organized overhaul of EHR design. Still, the value proposition for ACOs lies beyond EHR usability in four “must-win” health IT objectives.
(1) POINT-OF-CARE OPTIMIZATION
The baseline objective of EHRs is point-of-care optimization – better data collection to help providers keep pace with changing regulations. Many EHRs are not properly structured to meet the requirements the government has instituted on providers and, in the context of ACOs, there are new requirements.
Whether the goal is treatment recommendations, getting information on a lab result or providing patient education, optimization brings answers providers need into the workflow at the point of care. Ease of access to that information is particularly important when one considers the impact that clinical decision support can have on patient care. Hospitals and health systems are pushing their IT partners to get them into a paperless environment – Stage 7 on the HIMSS implementation scale – so they can be ready for value-based payment models.
Many providers and payers are proving that sharing patient data leads to high quality, low cost care, yet interoperability remains a challenge in most markets and electronic data sharing remains shallow. A major barrier is the lack of common data standards.
The Agency for Healthcare Research & Quality has recommended addressing this barrier by creating new software architecture altogether. The Office of the National Coordinator for Health Information Technology has laid out and revised a 10-year vision for overcoming the interoperability challenge that underscores the imperative to collect, share, and use digital health information. The interoperability issue will likely take a decade to address.
(3) DATA AGGREGATION
Healthcare must be personalized, preventive and continuous. The episodic approach to care we have today is at the core of the problem. Incentives for behavioral change need to be built into new healthcare delivery models. Rather than living in separate databases, information about blood pressure, sleep, fitness, nutrition and lab results need to be funneled into a common repository in real time – providing a single health dashboard from which users, and hopefully clinicians, can make better decisions. Aggregating health data is a great idea, but we need to do more with it.
(4) RISK STRATIFICATION
As value-based care delivery models like ACOs become more prevalent, risk stratification becomes increasingly important for population health management. Healthcare organizations working to change their cost structure and improve outcomes must design interventions that target high-risk, high-cost patients who need to be managed carefully and proactively.
The foundational step of targeting these high-risk patients is, of course, to identify them. For example, ACOs have to be able to pinpoint which heart failure patients are at high risk for readmission. Understanding comorbid conditions is a critical aspect of population health management because comorbidities are known to significantly increase risk and cost. Risk stratification applied at the point of care is the ultimate use of health IT for ACOs.