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Future ACO clinical decision support systems require heavy IT lifting

It takes a lot of heavy IT lifting to build patient-based clinical decision support for accountable care organizations, from HIE to analytics to EMRs.

In order to drive better outcomes while achieving cost savings, accountable care organizations (ACOs) will need to pull off some IT-intensive tricks, tying several large systems together. Clinical decision support (CDS) systems will have to tie into patient data polled from primary care physicians, specialists and hospitals through a health information exchange (HIE). Those HIEs must be populated with usable data -- read, consistently entered by all practitioners and fed to the exchange in an interoperable fashion -- from each individual electronic health record (HER) system, probably from competing vendors.

Read Part 2 of this series

ACO clinical decision support system solutions lie in mobile health

If that sounds like a tall order, considering how many practitioners either are still using paper workflows or are recent converts to the digital medical records era, it is. But some experts are of the opinion that not only is such a system feasible, but that the ACO era will eventually happen as the crumbling economic infrastructure of the present fee-for-service health care system caves in on itself and forces the adoption of another payment model.

But how do we get to real-time clinical decision support at the point of care from where we are now? Chris Cashwell, senior director for QualityAnalytics solution marketing for Burlington, Mass.-based Nuance Communications Inc., believes technologies such as speech recognition and clinical language processing filters -- which can ascertain one practitioner's "broken leg" in a medical record is the same as another's "fractured fibula" -- are key to feeding analytics programs that drive CDS.

Software that can do back-end processing and still allows practitioners to speak, not type or get lost in pages of check-boxes, he believes will be least disruptive to patient care, yet will help standardize data and make it more actionable in back-end systems. Queries within Nuance's software can identify patient conditions an ACO needs to report on, such as heart failure or pneumonia, mark them for the clinical decision support rules, and then check to see if practitioners executed evidence-based practices or not. While it's not yet real time, it's getting closer.

"We don't say 'real time,' because we don't want it to seem as if something happens instantaneously as the physician speaks," Cashwell said. "It is 'concurrent' -- a few hours later, as opposed to next quarter, when historically retrospective reports have been created."

He added: "When a patient comes in, we know if the patient has paralysis of the leg. We know they came in from a nursing home. We know if they have diabetes. We want to keep [your] grandma from getting a pressure sore, not learn next quarter how to keep the next grandma from getting a pressure sore."

Patient-centered medical homes, too

A separate-but-related issue is the patient-centered medical home (PCMH), a model of health care in which physicians and even community medical centers manage a patient's care with the same goals of boosting quality while reducing readmissions and costs. In fact, the Health Resources and Services Administration (HRSA) is investing grant monies for qualified clinics to become certified PCMHs.

Ascertaining that one practitioner's 'broken leg' in a medical record is the same as another's 'fractured fibula' is key to feeding analytics programs that drive CDS.

Like ACO participation, PCMH participation requires data collection, analytics and reporting. The California Primary Care Association has committed to getting all 900 of its licensed nonprofit members -- which range in size from small community clinics up to 25-site groups spanning multiple counties -- to achieve PCMH status, recently launching a Web portal with Arcadia Solutions to assist them in more quickly passing the National Committee for Quality Assurance's (NCQA) certification process. That can be a complicated process, especially for the largest CPCA members.

CPCA President Carmela Castellano-Garcia said the PCMH certification is one approach to getting clinics started in establishing the IT infrastructure needed for whatever quality-based payment models evolve in the coming years, whether it ends up being ACOs or something else.

"We'll be well-positioned, because of how our medical practice is structured and all the different components of the medical home that we think are central to all the different opportunities, going forward," Castellano-Garcia said, adding that some CPCA clinics are participating in CMS Health Homes demos for chronic disease patients on Medicaid. Most CPCA members have not joined ACOs yet. "So we see it as a critical strategy for our association."

The nuts and bolts of launching a medical home can help a physician develop the processes and software on the back end to fuel clinical decision support systems, said Andy Principe, vice president of health care solutions at Burlington, Mass.-based Arcadia Solutions. He believes ultimately they will help health care providers use decision support to drive continuous quality improvement.

"The medical home goes a long way toward getting there," Principe said. "Anything that we can do, that government can do to incentivize the transition to that model I think is ultimately the highest value work we can do to get there."

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