By Lisa A. Eramo
Without a doubt, healthcare data has become the industry’s greatest asset. Today’s electronic health records (EHRs) churn out volumes of this data for reimbursement, research, public health, quality improvement, and more. That’s why professionals trained in health information management and technology are critical to the success of the data-driven model for emerging Accountable Care Organizations.
Every provider wants to tap into the power of healthcare data, and Accountable Care Organizations (ACOs) are no different. An ACO is a network of providers and suppliers of Medicare-covered services (e.g., physicians, hospitals, and others involved in patient care) that share medical and financial responsibility for patients. The goal is to improve the coordination of care and avoid unnecessary duplication of services and medical errors. ACOs have come into existence thanks to the Affordable Care Act, which offers providers several models from which to choose.
Unlike disparate providers that operate independently, ACOs rely on shared clinical data. They’re all in the same boat seeking the same financial incentives for taking care of patients. Thus, their very foundation is built on the premise of care coordination. In a Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program, CMS states the following:
The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries, instead of the fragmented care that has so often been part of fee-for-service health care. The ACO will be a patient-centered organization where the patient and providers are true partners in care decisions.
At the heart of this seamless care is the clinical data that must be shared among members of the ACO network. Without this data, decisions are made in isolation and without context. The idea is that the true interoperability of clinical data among all providers who contribute to a patient’s care will result in the innovation of that care.
The EHR’s ability to capture clinical data for analysis continues to grow at lightning speed; however, interoperability remains a challenge. HIM professionals trained in health information management and technology must advocate for interoperability standards, particularly HL7 Version 3.
In addition to being interoperable, clinical data must be complete. The goal is to collect as much data as possible so that it accurately reflects the patient care provided and so that it tells the complete story. This panoramic view of patient care requires the following:
- Physician education regarding the importance of documentation, including documentation of all diagnoses that are treated and evaluated
- Proper coder training regarding reportable conditions and coding guidelines
- Healthcare IT investment that enables the collection of data and that capitalizes on data sources that already exist
Data integrity is also an important part of the equation. HIM professionals must advocate for thorough documentation and coding completeness. As technology is added to the picture, this integrity must remain intact. For example, HIM must ensure that codes generated via computer-assisted coding software are vetted and validated. As EHRs are implemented, HIM must ensure that copy-and-paste functionality is addressed and not abused. Integrity is of utmost importance in an ACO and for any provider rendering services today.
What does the future hold for ACOs? That depends on the clinical data—that is, whether it indicates that coordination of care equals better care.
Members of the ACO must remain dedicated to the cause, too. The shared savings must make it worth their while. Kaiser Health News reported in April that the ultimate goal would be for providers in an ACO to take full responsibility for caring for a population of patients for a fixed payment—something that Chas Roades, chief research officer at The Advisory Board Company in Washington D.C., told Kaiser would require an entirely different type of transition.
However, Kaiser reported that in July, nearly one-third of the participants in CMS’ Pioneer ACO model left the ACO because they either hadn’t saved enough money or preferred to participate in a model with less financial risk.
Given the challenges of interoperability and data collection that still exist today, it’s not surprising that the shared savings for ACOs have been less than expected. HIM professionals must learn to be creative in developing new ways in which to capture, validate, and harness the clinical data that could make or break these networks.