Commercial ACO efforts in Michigan have yet to appear, although the patient-centered medical home model is beginning to catch on, Dietzman says. "Larger health systems are trying to make sure they are well-coordinated with providers in their communities that serve as their referral base," he says. And that care coordination sets the stage for ACO payment models, he adds.
Physicians looking to automate their practices with EHRs often have little understanding of the limitations of the technology and the need for an HIE, Dietzman says. "The EHR can do a great job in the physician practice, but it doesn't know who else has an EHR in the community or what is needed for a referral outside the practice," he observes. That's why, even with an EHR in place, managing referrals is a paper-centric process.
Despite such limitations, the EHR is the cornerstone of accountable care, many experts say. But more is not necessarily merrier. Bond, the CEO at Cox Health Plans, notes that its health system runs on one EHR, an inpatient system from Cerner, while physicians use an ambulatory system from GE. Under fee-for-service payments, neither side had incentives to coordinate care. But now, with pay for performance looming, the health system realizes that will have to change, Bond says, and add more robust data management tools to the mix. "We have recognized that we will need one record system," Bond says. "It's imperative."
Advocate is also looking to minimize the number of ambulatory EHRs in play. Four years ago, it began deploying an Allscripts EHR among its large group practice of employed physicians and mandating its use, Shields says. About 800 of the 1,000 physicians are now on the system. Its independent physicians, however, are gravitating toward a system designed for small practices from eClinicalWorks. About 400 physicians are on that system, whose cost Advocate is helping to subsidize via the Stark relaxation rule.
But all physicians, even those still on paper charts, are required to use a Web-based disease registry, from Intelligent Health Care. The registry takes data from lab visits, pharmacy, and claims, creating rosters of patients with various chronic diseases. The system will flag patients in need of certain tests, providing alerts to the physician practices. "A well-deployed EHR is highly desirable, but you can get a lot of mileage with a simpler, easy to deploy tool like the registry," says Shields, the senior medical director.
Advocate reinforces its efforts with a centralized group of 60 outpatient case managers who use the disease registry. The registry works in conjunction with predictive modeling software from ActiveHealth, flagging patients at high risk of hospitalization. The goal is more proactive management of care coordination around patients who need it most. Shields says that the next step will be better patient engagement with their own care. "We need to provide prompts and reminders to patients," he says. Among the technologies under consideration for a more expanded role is the personal health record.
Chris Van Pelt, the senior vice president and CIO of Indiana University Health, says the PHR has potential to influence patient compliance-but that it's no substitute for an EHR when it comes to care coordination. The health system is currently evaluating multiple ACO options. "The ACO is the right direction to head, but much is uncertain and defined," Van Pelt says. "The challenge is care coordination especially managing chronic patients. We are trying to focus on 'high-consumption' patient populations."
Van Pelt sees potential in chronic condition management clinics, a set-up similar to a medical home where one practice would serve as the care overseer. "But you still need to engage the patient so they don't end up in the ED," he says. The PHR is one way to engage patients, by giving them a vehicle to record their own data. And IU is sorting through three PHRs working in conjunction with various systems in play at its hospitals to see which offers the best patient experience. "Ideally we will be converging on a cloud-based PHR that operates agnostic of any EHR," he says.
PHR advocates say the technology could serve as a common source of information among different providers. In this view, patients serve as their own care coordinators, deploying their PHR as a common communication ground among their providers.
But Van Pelt says this vision may be a long time coming. "People are more interested in updating Twitter and Facebook than they are engaging with their electronic medical records," he says. "There is really low engagement for PHRs right now, but you don't abandon that space."
Wanted: I.T. Tools
Following is a short wish list of I.T. tools industry leaders say will be needed to support accountable care.
* Chronic condition surveillance. Chris Van Pelt, senior vice president and CIO at Bloomington-based Indiana University Health, says his organization would benefit by receiving electronic prompts every time one of its patients showed up at an out-of-network emergency department. "We need to get an alert that the patient presented at another ED and let the physician who owns that patient in the ACO model know," he says. "That would alert the physician to take action."
* Access to payer formulary. Having direct access to a list of preferred drugs supported by payers would enhance electronic prescribing already in place, says Heidi Moore, MD, a pediatrician who serves on the executive board of the Northern Adirondack Medical Home Project. Moore currently uses her EHR to prescribe meds. "It would be really nice if the list were there so I don't prescribe a nose spray and 30 minutes later get call because it is not on the formulary," she says.
* Home-based medical devices. Jim Adams, managing director of The Advisory Board Company, says home monitoring devices, which can relay data back to providers, will help enhance patient accountability in the ACO equation. Pointing to the potentially high cost of treating "dual eligibles," elderly, low-income patients enrolled in both Medicaid and Medicare, he sees the devices as expanding in importance in the years ahead-largely spurred by the shifting economics of care delivery and reimbursement. "Accountability will be pushed out to the patients via higher deductibles and co-pays."