Getting ready for emerging care models

Getting ready for emerging care models

Like it or not change is coming to healthcare. The government, employer groups and other purchasers of healthcare are demanding higher quality and lower costs in the delivery of healthcare. The Affordable Care Act of 2010 started this evolution and whatever you call it -- value-based purchasing, accountable care, patient-centered healthcare, etc. -- it is taking root and starting to grow rapidly. Today there are over 300 accountable care organizations (ACOs) in this country touching between 25 and 30 million patients. 

So the question you should be asking is: What should your practices be doing to prepare for participation in emerging care delivery and value-based reimbursement models such as ACOs or patient-centered medical homes (PCMHs)?

There are a number of things physician practices can be doing right now to prepare to participate in value-based care delivery models (e.g., ACOs, clinically integrated networks, PCMHs, etc.). Preparation falls into three areas: people, processes and technology. This article will focus on the foundational technology layer or "table stakes" necessary to participate in these new delivery models.

To get an idea of what you should be thinking about, let’s look to a healthcare market where these “new” healthcare delivery models are the norm and have been in place for years. One such market is in the Netherlands, where 90 percent of demand for care is generated in the primary care setting and providers (private) are paid a lump sum based on conditions and work in integrated care networks.

In the Netherlands today, 99 percent of physicians use a computer, 97 percent are Internet-enabled, 90 percent store all types of health records electronically, 84 percent receive lab results electronically, and 26 percent exchange data electronically with other providers – all benchmarks that the United States aims to achieve in the next 3-5 years. The international standards used in the Netherlands are consistent with U.S. conventions, as HL7 and ICD-9 are used in healthcare and ICD-10 is being adopted. Also, as in the United States, Holland does not have a dedicated health ID number or “smart card” for patients that some European countries have adopted but which are not relevant in this country. In these respects, the Dutch market is extremely similar to the U.S. market. This market is where our own company history started, and where our care collaboration and disease management solutions have matured.

Here is what you need and why
To participate in a value-based delivery model you must be willing and able to coordinate and collaborate on patient care with other ambulatory providers; the goal is to render the right amount of preventive care, avoiding health complications and resulting in better patient care with lower attendant costs. Once this mind shift has taken root -- a very different and, for some, a difficult way of thinking -- you need the basic tools and capabilities to engage in care coordination. These tools must:

  • Enable you to store patient information electronically. This does not have to be the typical full-blown EMR that legacy vendors have been marketing. These EMRs were developed in the fee-for-service model to optimize billing and reimbursement and resemble digital renditions of paper records. Not to mention they are expensive to acquire and maintain even when they may be subsidized by the ACO. Instead, you need a platform that is designed for the new delivery model focused on optimizing patient care, with a workflow that fits your practice pattern. For more on this see the 2010 PCAST Report titled "Realizing The Full Potential of Healthcare Information Technology to Improve Healthcare."
  • Enable patient-centric care, including making sure that patients receive reminders for preventive services through multiple channels based on their personal profile.
  • Support the care team network, allowing all providers, physicians, facilities, etc., involved in treating particular patients to share relevant information through collaborative and coordinated care.
  • Manage patients proactively.
  • Be able to generate electronic referrals.
  • Be a cloud-based solution. Cloud-based solutions require little or no local IT support and investment. This is really important for the average physician practice. Also the pricing level and payment structure with predictable cash flow more closely matches the size of the practice.

To distill down these capabilities into specific tool sets means you should expect to have the following: an EHR; a care collaboration/coordination solution; and the ability to exchange electronic referrals. The key in selecting the right solutions for your practice is to pick one with the right workflow for your practice. The solution(s) must be cloud-based so you can avoid the costly hassle of purchasing and supporting local software installations, which is expensive and not your core competency. If you do not have these capabilities you either might not be a candidate to participate in an ACO, clinically integrated care delivery network or PCMH, or the ACO will force you to use their solutions.

You should expect the ACO to provide other required solution capabilities such as clinical decision support (CDS), analytics, population health tools, health information exchange platform (HIE); reporting tools, etc. These are expensive solutions tailored for a large organization to manage and support.

Finding the right solution (s) can be difficult
The key challenges you face are: (1) most providers are too busy taking care of patients to acquire sufficient knowledge about emerging eHealth solutions; and (2) most providers do not possess the IT and vendor purchasing experience larger organizations have with dedicated IT departments.

As a result, many providers turn to the usual list of vendor suspects for healthcare IT solutions. The issue with most legacy healthcare IT vendors is that most of their solutions were designed in the fee-for-service model and not optimized for patient care. They are committed to their current solutions and architecture because they have large installed bases and cannot easily change the structure of their solutions to meet the needs of this new care delivery paradigm. 

The rapid creative destruction (read: better stuff, faster and cheaper) that has been experienced in other industries (think smartphones and iPads replacing expensive desktop computers) is only now coming to healthcare. For more on this see Forbes magazine September 2012, "Healthcare IT is Terrible and Expensive."

Worse still, most of these legacy vendors’ products were designed when self-contained silos of information were the norm, which is just the opposite of what you will need to be ready to participate in the new care delivery models.

Even though the right solution may seem difficult to find, the healthcare industry has seen an enormous influx of new, innovative vendors that have fully embraced the cloud-based computing paradigm. The right solution for your practice is probably already out there, enabling the support you need for your workflow and your specialty of care.

Andrew Pashman is director of business development at VitalHealth Software, a developer of cloud-based software for health management. The company, founded as a collaboration between the Noaber Foundation and Mayo Clinic, focuses on disease management, health network management and personal health management.