This Q&A features Mark Caron, senior vice president and CIO of Capital BlueCross, who has three decades of business and technology expertise. Prior to joining Capital BlueCross, he was CIO at the newly created Collaborative Care division of OptumHealth. His experience includes senior leadership roles with BlueCross BlueShield of Wisconsin and Massachusetts, Catholic Health Initiatives and Healthsource.
SearchHealthIT.com HIT reporter Don Fluckinger sat down with Caron to discuss how health information exchange (HIE), a significant component of meaningful use stages 2 and 3, fits into the changing landscape of health care payment models
Don Fluckinger: Both the HITECH Act and the health reform law require greater sharing of data to improve care. Can health information exchanges be leveraged to foster communication within accountable care organizations (ACOs)?
Mark Caron: I believe they can. I think the interesting thing is the maturation process of information exchanges. There are some markets where those HIEs are maturing faster than others. So I think in rural markets where they haven't been matured yet or haven’t been built, you can create what I would call a "pseudo-HIE" within your own ACO that allows you to share information among those physicians, facilities, hospitals and payers around that population they're trying to manage and improve care quality and reduce costs.
It can be as simple as sending admissions-exchange-transfer data within an ACO. [This] informs [the ACO] that the hospital is generating a discharge or an event, such as a patient has registered in the ER or is going to be admitted. That should kick off some care coordination model that would connect that continuum to ensure -- as the patient's acute situation is being cared for, as the transition plan is being developed, as the discharge planning's being developed -- all those constituents within that continuum understand what the next steps are for that patient: a followup visit, medication adherence problem or challenge, or the basic continuity of care document (CCD) information being passed along so the primary care physician is aware of what the patient was dealing with in the hospital.
DF: What role will the Direct messaging standard play in HIE? Tennessee is backing off on its statewide HIE and recommending Direct as a substitute, and other states are encouraging use of Direct at this point.
Caron: I think there are two things around that. One, it gets to the real question of sustainability of HIEs, and funding, and how that's going to continue. Direct, as a short-term approach to getting information exchanging is okay, but it's not integrated. It's what I would call "secured sneakernet," in the sense that it's taking a fax, a CCD, and turning it into a PDF and sending it as that output. Whereas with a fully integrated HIE you're going to have those data elements reside [inside an EHR] and be able to be updated. I believe Direct will have a role. It also gets back to the point I made earlier about the maturation level of HIEs and the rural nature of health care in many areas of the country where you may have a primary care doc in a small community sending the CCD to a specialist 60 miles away to give that specialist at least an update on the patient's medical record. It's a Band-Aid approach that will help, but it's manual in the sense that it's in a document that has to be updated to a file -- so it has potential issues with data quality.
DF: What components, including technical and leadership, make up a successful ACO model?
Caron: It takes commitment on all parties' parts. It's not an IT project, it's actually a clinical project. In a practice you need to have the physician on board, the office management staff on board. In a hospital facility you need to have clinical leadership and their technical teams, but everybody's got to have this commitment to "here's the data that we want to exchange, this is how we're going to use it, and here's how we're going to report from it."
You really need to have all the top people supporting this, because [for example] if you have a chief medical officer in a hospital who isn't supporting this, it's going to be viewed as sort of a shadow project, and you won't ever reach the highest expectations of data integration, information exchange, improving quality outcomes and reducing unnecessary services.
DF: Patient data tends to get stuck in various departments within the health system. How can organizations break down "siloes" of information?
Caron: Another key component of a successful ACO is the governance model and the governance process. Representatives from each entity -- each department in the hospital or health system -- are sitting on this committee and supporting the various data that will be exchanged, the agreements of data that will be exchanged, how it will be used, what the reporting needs are. That's the key; that's how you break the silos.
DF: The adoption of technology has led to even more questions about reimbursement and payment reform. What shape will that reform need to take to align incentives with the use of IT tools such as remote monitoring, data analytics and quality metrics?
Caron: If the goal is to continually bend the cost curve down and to find the most appropriate place of care, then we need to come up with more contemporized models of care -- remote monitoring, teleconferencing video, things to allow care to be delivered in a remote location -- either by a physician extender or a family member helping the primary care physician in a home setting -- I think those have to be. The ability to provide reimbursement for those services are key. [Also key will be] continually driving for quality measures to be a key component of reimbursement. [Furthermore], process measures that tie into data analytics driving evidence-based medicine and protocols of care. HITECH should be a continual process improvement tool that ties off of those components I just mentioned to reimbursement -- and more importantly, quality outcomes.
DF: You bring up telemedicine -- interesting coming from a Blue. Usually Medicare drives commercial reimbursement strategies, but in the case of telemedicine it's the reverse: Commercial payers are doing it, and Medicare is being dragged into it, slowly. Why is the pattern reversed in this case?
Caron: I think CMS has always questioned the setting, perhaps the physician extender's ability to provide the quality of care. If we're looking to reduce our costs, the only answer is to identify ways -- not only to reduce costs, but we have a capacity problem ... we don't have enough docs, we don't have enough nurses. We need to look at alternative care deliverers. I think a big part of the solution is telemedicine or whatever we want to call it today.
DF: Based on your experiences with health plans and hospitals, what are the top three things that will transform the industry over the next 5 years?
Caron: One, reimbursement. It's all about reimbursement and gain-sharing incentives tied to quality, tied to outcomes.
Three, the evolution of HITECH to include more advanced technologies in the home, at the point of care, that is more ubiquitous and less facility focused. You may be able to do a consult over your cell phone via video with your doc because you don't feel well ... and provide a mechanism for that physician to get some sort of reimbursement for that patient. That, and consumer-based tools that provide consumers access to information about their health at the point of care, so they can make better decisions about where to get the kind of care they need, what that cost is [and] transparency about who the high-quality/low-cost providers are in their markets.