Coordinating Care for Quality and Efficiency From the start, the ACO needs to consider ways to communicate relevant information from its data exchange with providers and patients, particularly when changes are warranted to better meet the patients’ needs. After all, such improvements in care are essential for the ACO’s success. The ACO should adopt, whenever possible, valid evidence- based care guidelines, and use data exchanges to identify and intervene with physicians when the care provided falls outside of these guidelines. As an example, working with providers of care for lower- back pain, an ACO may establish a guideline that advocates physical therapy be tried before referring certain patients for a radiology imaging test or to
an orthopedic surgeon. The guideline is designed to achieve both quality and efficiency goals. For Medicare patients, guidelines that help physicians determine the appropriate course of action may be especially important, as these patients often have several co-morbidities. Better coordination and communication among physicians will help clarify which conditions to treat first.
For these efforts to improve care delivery to succeed, the ACO needs to dedicate resources to assist physicians with appropriate patient care management. To do this, the ACO will need to use the data exchange to address six key areas: 1. The patients’ treatment needs based on
evidence-based guidelines;
2. The physician’s performance with respect to meeting the patients’ needs;
3. The benchmarks for the cost of care; 4. The physician cost of care relative to these
benchmarks;
5. The organization’s effectiveness in improving quality; and
6. The organization’s costs of care compared to its benchmarks and budget.
The Case for Disease Registries
Disease registries, without EHRs or with limited or more comprehensive EHRs, offer an effective, relatively inexpensive tool for identifying and addressing gaps in quality through an ACO data exchange. They can serve the dual purpose of providing timely information for care improvement, and the generation of performance measures for ACO payment contracts. Kaiser Permanente, the Group Health Cooperative, and other integrated- care organizations have achieved measurable quality improvements using disease registries, which identify whether the evidence-based needs of patients are being met, and track the physicians’ and the organization’s performance on quality measures. Advocate Health Care, the largest not- for-profit delivery system in metropolitan Chicago,
has successfully integrated data by instituting data registries to manage the care and track the performance of its primary care and specialist physicians. Advocate Physician Partners’ Clinical Integration Program uses a registry that tracks 15 distinct diseases and preventive care populations, and assesses its performance on 110 clinical and efficiency measures.6 In the Medicare PGP demonstration project, all ten participants utilized a disease registry to track the patients with diabetes. Note that providers do not need to be associated with integrated delivery systems to use registries. Several states and other regional initiatives are supporting the development of health information exchanges that can support disease registries. Employed in a wide range of care settings, disease registries today provide web-based options that allow physicians in various locations to access the same data. Full implementation of an EHR is not required, but it is necessary to have sufficient, timely administrative and clinical data exchanges to reliably identify meaningful opportunities for improving quality and cost. An EHR can provide the most up-to-date information on a patient, but it may be incomplete if it relies only on internal data or on systems that are not comprehensive. While potentially more limited in scope, an ACO disease registry combines limited internal and external data sources to address clear opportunities to improve care, by identifying patients with common needs – including specific diseases and/or qualifying for preventive care services – and providing timely information to help address unmet needs.
The data exchange should automatically populate the disease registries with data from physician billing, EHRs, medical claims, encounter data, hospitalization, laboratory test results, and pharmacy claims or e-prescribing to pinpoint any unmet needs, gaps in data, or gaps in service delivery. For example, a typical set of registry tools for a Medicare population should be able to identify and track populations with diabetes,
acute and chronic cardiovascular diseases, heart failure, hypertension, osteoporosis, and end-stage renal disease. The set should also be able to track patients who are on persistent or high-risk medications.
For preventive care, registries should track colorectal cancer screening, breast cancer screening, and annual flu shots. While registries used to be maintained on paper, today’s web- based, pre-populated registries derived from electronic data exchanges can provide physicians and other members of the care team with point of care and near-real time gap analysis to see if evidence-based services are missing or needed by their patients. Registries can also provide regularly updated feedback to physicians indicating the progress towards measurable goals of improvement in patient care.
The ACO, working with its payers and providers, will establish goals for quality improvement based on the historical data for its population and priorities. Capabilities to support the quality measures should be incorporated into the disease registry. For example, if care for patients with diabetes is an ACO focus, data on patients with diabetes should be captured as part of the registry, including valid measures such as use of diabetes screening tests and occurrence of preventable readmissions plus clinical results (such as hemoglobin A1c levels), if feasible. If flu shots are one of the measures, patients who should have annual flu shots should be an additional registry. Populating the registry with data on occurrence of flu shots – along with an opportunity to add data on shots not captured through administrative systems – then supports both improved clinical care and performance measurement. Organizations that have used registries for several years may be tracking patients in ten or more distinct registries. The registry tools available today are able to support registries for any distinct population that needs to be tracked by the ACO.
To illustrate how the disease registry process works, high-cost and high-risk patients – who need coordinated care the most – are identified in the data exchange either automatically from the claims data (through predictive modeling, for example) or by physicians adding these patients. If the ACO utilizes non-physician care coordinators in its care team, the coordinators then use the disease registry to track the care against the guidelines established
by the ACO and work with the physicians to
address any gaps in care. Such capability provides the entire organization with the ability to view all the practice settings at once. For example, Exhibit 4.1 shows how viewing individual patient-level integrated clinical data can enable the physicians to coordinate, monitor, and provide the appropriate treatments for the patient.
Jane Smith, Patient with Diabetes
ACO Data Exchange and Disease Registries
Mammography Endocrinologist Lab Test Results
Pharmacy
OB-GYN
Primary Care Physician
Primary Care Physician • OB-GYN • Endocrinologist EXHIBIT 4.1. CLINICAL DATA INTEGRATION ENABLES ALL THE