Coordinated Care and HIE Framework

Avatar photo Team Zaloni February 16th, 2016

Accountable Care Organizations

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

Another way to view Accountable Care Organizations (ACOs) is as the logical/preferred organizational end state that follows in the path established by the Patient Protection and Affordable Care Act and the Medicare Shared Service Program.

Patient Protection and Affordable care act - 2010

ACO operations involve the integration of massive amounts of data that establish baseline clinical performance measures and operational performance measures, ensure compliance with Safe Harbor and data security considerations, integrate EHR and other “HIT data sources” to meet CMS Meaningful Use and interoperability requirements.

Commercial payers, such as UHC, BCBS, Cigna and Aetna all support ACO formation, aligning pay for performance, pay for outcomes incentives benefitting existing ACO style provider groups and related health systems or through their own sponsored physician groups and providers.

The fast adoption of a robust data technology infrastructure that supports the integration of massive amounts of data is essential to the streamlined operation of an ACO. This foundational data management helps establish baseline clinical performance measures and advanced operational streamlining stretch goals. The goals ensure data security, data privacy, Safe Harbor, full integration of EHR and other HIT sources to meet stringent CMS interoperability requirements.

Tackling data lake complications

Managed data lakes and their related technology capabilities are needed to support such levels of continuity of care and enhanced provider collaboration. The capabilities required include:

  • Data & workflow integration across the disparate information systems – EHRs, Lab systems, Pharmacy systems etc.
  • A unified view of the patient across organizations and facilities where care is provided
  • Continuous live updates from participating entities – e.g. ADT (Admission, Discharge and Transfer) and Pharmacy Fill History
  • Communication of such updates to the appropriate physician and care giver to ensure care synchronization
  • Clinical alerts to ensure adherence to the latest approved care guidelines and protocol
  • Aggregation of patient information enabling quantitative analysis of outcomes and quality of care
  • Insights derived from diverse patient populations for clinical outcomes management

This managed data lake and foundational data management infrastructure goes a long way in providing meaningful coherence between systems that don’t speak the same language. This feature, “semantic interoperability” is vital to realizing the potential of sharing information throughout the continuum of care. This enables updates across multiple physician practices, health systems and allied health providers seamlessly and efficiently.

The multitude of code sets (LOINC, SNOMED, ICD 9, CPT etc.) and specialist terminologies makes this level of data harmonization extremely onerous when coupled with the subtle nuances of clinician friendly terminology and free-text doctor notes.

In the siloed US healthcare system, multiple encounters are not linked across organizational and partner information systems.  To effectively manage clinical information in an ACO it is essential for data management technology to correctly aggregate multiple encounters so that when a patient presents himself, a physician or care giver can quickly search for all past clinical & insurance data about this patient from any and all previous visits/locations to any provider. This implies robust Master Patient Index and Master Provider Index capabilities to also be fully integrated with clinical transactions/patient encounter data.

Managed Data Lakes and related data management technologies complement each other in realizing the three critical factors for ACO success:

  • Comprehensive stakeholder collaboration
  • End-to-end care delivery network
  • Strong technology infrastructure bringing together health records patient populations and clinical decision support

The critical functionality that the managed data lakes technology framework for an ACO must include for successful operation.

  • Aggregated patient records and health information from all connected stakeholders aka a current, updated longitudinal patient record
  • Identity management services that ensure identification of a patient
  • Security management services that protect PHI and provide for data masking and access control
  • Terminology services that ensure data is semantically correct across all data sources
  • Support for patient registries and disease management tools that leverage information retrieval from the Data Lake via industry standard APIs such as FHIR
  • Gateway services for the exchange of information with external networks such as the NHIN, other HIEs and public health agencies.

Such a continuum of care based data management technology framework enables high quality patient care that is coordinated across multiple  provider stakeholders, the patient’s personal physician and nurse/transitional care givers.

To learn more about managed data lakes, foundational data management platforms for health and life sciences, watch our on demand webinar on Health Informatics and Managed Data Lakes:

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about the author

This team of authors from Team Zaloni provide their expertise, best practices, tips and tricks and use cases across varied topics incuding: data governance, data catalog, dataops, observability, and so much more.