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Can HIE technology be extended to the ACO model?

Don Fluckinger, News Director

BOSTON -- A group of physicians hope to prove that their health information exchange (HIE) technology can become an accountable care organization (ACO), but whether such a model would be sustainable remains to be seen.

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At this year's Lawson Software Inc. Conference and User Exchange (CUE) 2011, health care providers demonstrated new ways of mashing up clinical and back-office workflows in an effort to cut costs through creative data integration. One of those projects came from Sandlot LLC, a private HIE owned by North Texas Specialty Physicians.

Sandlot's innovation? It's an HIE creating its own ACO.

NTSP is a group of 600 independent specialty and primary care doctors using Lawson's HIE technology to connect to each other as well as hospitals, lab facilities, ambulatory surgery centers and radiology groups throughout the Dallas-Fort Worth region. As NTSP’s wholly-owned subsidiary, Sandlot hopes to market its HIE technology and, ultimately, ACO setups to other medical groups.

The HIE has a long way to go before the Centers for Medicare & Medicaid Services (CMS) starts doling out dollars to Sandlot to fund patient care coordination -- especially considering that the 429-page proposed ACO rule just hit the streets at the end of March. But Sandlot chief medical information officer and practicing gastroenterologist Dr. Tom Deas said that the company will consider applying to become an ACO.

Risk management key to extending HIE technology

Sandlot wouldn't fit the ACO model that Medicare is currently proposing, Deas said. However, with its varied member base of specialist physicians, and with its ability to feed Continuity of Care Document data throughout its network to electronic health record (EHR) and lab systems, his organization could handle the IT heavy lifting that ACOs require.

The NTSP patient population features many enrollees in Medicaid Advantage, an insurance plan with capitated payments. Such plans, which also include Medicare Advantage and certain private insurers, provide a fixed amount per patient, regardless of the number of visits or services performed.

Deas spoke on the phone from Texas while his colleagues demonstrated their product, known as SandlotConnect, in Boston. Deas said that Medicare's shared-savings model -- which may pay off two or three years down the road -- doesn't quite mesh economically with NTSP's needs.

"We're not enthusiastic about the model that is proposed," Deas said. However, he added, if an alternative payment model could be worked, then the physician group and the HIE would have the IT backbone with SandlotConnect to provide care coordination required of an ACO.

"We will very likely submit an application to the CMS Innovation Center to create an ACO model based on risk management, which is what we've been doing for 15 years with Medicare Advantage and other capitated plans," Deas said.

Expanding the enterprise HIE to serve ACO requirements is a logical build-out, is repeatable and, if done properly, sustainable.

John Moore, principal analyst, Chilmark Research

That's not just blind optimism. CMS has set aside more than $15 million for Medicare and Medicaid payment innovation pilot projects. Deas said he is optimistic Sandlot will be able to draw up a plan offering capitated payments up front and bonuses based on quality goals that will satisfy CMS requirements as well as NTSP stakeholders.

Sandlot offers another advantage, Deas said. Among other criteria, the federally proposed ACOs require two things. The first is a way to collect patient data. Two obvious ways to collect that data would be with either a clinical data warehouse or, alternately, a HIE set up to handle analytics. The second is a set of decision support rules that stems from those analytics. "I wouldn't let the word 'ACO' out of my mouth if I didn't have a tool like Sandlot Connect to help manage that process," he said.

Could this HIE-ACO model be copied?

In the CUE2011 demo, Deas traces a story of an elderly liver cirrhosis patient, and her care through the health information exchange when she arrives at his office confused and unable to provide even recent medical history. Without current, detailed, continuously updated patient data from all providers, Deas might have ordered many tests or even sent her to an emergency department. Instead, Deas was able to determine that one of her prescriptions was causing her symptoms and simply change it.

The company created an interoperable system, and SandlotConnect currently supports EHR systems from Allscripts Healthcare Solutions Inc., Epic Systems Inc., eClinicalWorks LLC, NextGen Healthcare Information Systems Inc. and Quest Diagnostics Inc. Others will be added. "We feel that there are others that would fit specialties that our physicians have better than those," Sandlot vice president Jerry Malone said.

Could such a model, regardless of software vendor, support ACOs and at the same time give a survival mechanism to HIEs, some of which are struggling to maintain financing? Could it be replicated elsewhere?

John Moore, principal analyst for Chilmark Research, which recently published a market report on HIE software, thinks that general concept is plausible.

"Much of the HIE sustainability issues revolve around pseudo-public HIEs formed with grant money to serve local community public health needs," Moore said in an email to SearchHealthIT.com. "It is most often these HIEs that have struggled with creating a sustainable business model. Private, enterprise HIEs have very specific, focused objectives and have been more successful. Expanding the enterprise HIE to serve ACO requirements is a logical build-out, is repeatable and, if done properly, sustainable."

Deas thinks the HIE-ACO idea could be copied among other physician groups -- but only if they were willing to learn the technology and also to change their practice patterns according to the decision support rules the ACO adopts. Perhaps the most important IT support any ACO needs, he said, is access to a patient record that shows treatment from all physicians, specialists and hospitals in a network, as close to real-time as possible.

"That's the primary function of a community HIE -- making all the information available," Deas said.

Centralized HIE technology, though less popular, might make best ACO

Health information exchanges typically operate under one of three HIE models:

  • centralized, in which members log into a central repository and take away files;
  • federated, which is more like a peer-to-peer network that includes an edge server authenticating logins and cataloging what information is where, and
  • hybrid, which  stores data in a central server for finite periods for the purpose of compiling reports.

In some cases, hybrid health information exchanges collect data for creating snapshot reports, hold it for a time, then discard it after the reporting is complete, Moore said.

The federated model seems to be gaining popularity in the United States, since the centralized model requires more overhead and data protection to get in compliance with state and federal privacy laws.

However, a centralized model such as Sandlot Connect would have an easy time running data analytics in order to generate information such as the 65 quality reports required in the proposed ACO rule, Moore said, though a hybrid data model may also be able to accomplish that, too.

Let us know what you think about the story; email Don Fluckinger, Features Writer.


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