INDUSTRY EXCLUSIVE: CSC's New Report Looks at the Challenges Inherent in Leveraging Data for Accountable Care

So for your high-risk patients, you may want to engage in obtaining medication histories regularly, because there could be an associated cost—so that you can compare those to the prescription information you have in your EHRs, so you know sooner than when they show up in the emergency room that they’re not picking up their meds for cardiac issues, or whatever. So this is really the complexity of it: not all sources are available for all types of patients, and there isn’t an equal level of urgency in terms of finding things out for all patients. So that really helped us think through what you might need to do here, because you might have multiple ways to do things.

Many of the sources you looked at are (or are related to) health plans or other payers.

Yes, the organizations that administer health insurance—public or private—have a wealth of information, much of it highly standardized and coded.  We looked at information stored from several related electronic communications between providers and health insurers or other payers around eligibility verification and referral authorization, claims, of course, and information about medications from Pharmacy Benefits Management (PBM) companies or pharmacy network providers such as Surescripts.  The advantage of all of these is that they are all more comprehensive than the information in the local EHR, except in the rare instance that a patient never accesses care outside of a health system with a fully implemented, comprehensive EHR.  That situation isn’t true for most patients.

Is all of this automatically available?  Is any of it in use today?

Iwouldn’t assume that anything is available without extensive negotiations and possibly even some financial agreements.  Plus there is additional work to put the information to work—integrate it with other information, get it to the right person at the right time, etc. But Coordinated Care Delivery Organizations [what we call ACOs] are already getting claims information updates monthly from Medicare and other payers.  Collaborative arrangements between private insurers are becoming more common, and some of the big national companies like Cigna and Aetna have national programs.  When I was looking recently at models for coordinated care, I found numerous examples where providers were already receiving notification when covered patients popped up in emergency rooms and as emergency admissions—the payer would provide work lists for case managers or care coordinators each morning.  And Surescripts reports that it provided medication history 586 million times in 2012.  So, yes, tapping these external sources is possible, but certainly not automatic.

You also looked at case management systems as a piece of the information puzzle.

Yes, that is likely to be the only electronic record of who’s on point for case management or care coordination and the current care coordination plan.  Care coordination—as opposed to clinical care—must also be “coordinated,” if you will to avoid overlapping, and, to the patient confusing, monitoring and support.  Plus, if data analytics are ever to help case managers cut down on telephone calls to see how patients are doing, the basic information about care coordination needs to be tied in.  Obvious examples would include lists of recently discharged patients who missed their scheduled follow-up appointment, or high-risk patients not complying with their regimen of prescribed medications.

You tied your look at exchanging information with external EHRs to HITECH meaningful use. Can you explain some of the thinking there?

HITECH requires specific capabilities for information exchange in certified EHR technology and makes HIE-related use a requirement of meaningful use by providers.  At least in the near term, the electronic structures and use cases defined for HITECH are likely to be most broadly available within any community of hospital and physician participants in a CCDO.  In Stage 1 requires exchange of very basic information—allergies, medications, problems, and lab results—a core information set for any patient.  Stage 2 advances to two very high-priority use cases for transitions in care:  for hospitals, the discharge summary, and for EPs, the referral request. HITECH also provides HIT capability for document exchange by requiring summary of care records to be displayable in human-readable form.

Is a lack of granularity of data exchange standards an obstacle in that regard?

I think it’s a continuing obstacle. I think we’ve made some progress because of HITECH. But I think there aren’t just problems with the coding structures; people still think there are gaps and lack of sufficient granularity in LOINC. I’m on a listserv with people who are currently having the same conversation about SNOMED, which, as applied to EHRs is still relatively new for most people. And there are all kinds of issues about usability, particularly since having the provider assign the code, at least for billing purposes, has been the norm under ICD-9, so there’s a lot of work to be done there; but also with regard to the packaging of standards. We looked at what HITECH says you need to be exchanging, because we thought that that was the near-term, most-likely-available, capability. And if you look at the details of that, even in Stage 2, only the most core information—problems, medications, allergies—really has to be data-coded to stated standards. So even this discharge summary has a lot of information in it that doesn’t have to be coded; it has to be extractable for human readability.