For accountable care organizations, a lack of interoperability between their health information technology systems and those of providers outside their ACO is the No. 1 challenge they face, cited by 79% of respondents to a survey of 68 ACOs by group purchaser and performance-improvement company Premier and health IT collaborative eHealth Initiative.
“Obtaining data from settings outside a network requires complex data-sharing agreements and new interfaces between systems,” according to the authors of the 10-page survey report, The Evolving Nature of Accountable Care.
“Unfortunately for ACOs, their need to manage entire patient populations also requires that they integrate data from many of these disparate systems,” the report authors said. For several reasons, ACOs are “struggling to integrate data from disparate clinical sources” into their care delivery processes.
The inability to exchange patients' electronic health records and information was most acute with medical specialists. “Often, these practices lack the proper incentives to share their data.” As a consequence, 69% of the ACO respondents surveyed reported “having a harder time integrating specialty-care data, almost double the number for any other care setting.”
Sending and receiving data from providers outside of their own ACO network also “requires complex data-sharing agreements and new interfaces between systems,” the report said.
ACOs are also having a tough time connecting with providers that did not receive federal electronic health record incentive payments—behavioral health, long-term, post-acute care and hospice organizations—the survey report said.
Fifty-three percent of ACOs have not integrated data from behavioral-health providers, according to respondents, and 48% don't have data integration with long-term and post-acute care providers. Another 46% of respondents report not integrating their systems with palliative care and hospice organizations.
“Of all care settings, surveyed ACOs would most like to have greater interoperability with behavioral health and long-term/post-acute care (tied at 67%) to support operations,” the report said. “ACOs that have attempted to integrate data from these sources rate the experience as more difficult than other settings.”
Behavioral health, long-term, post-acute and palliative care providers were ineligible to participate in the federal incentive payment program that has doled out more than $31.8 billion since 2011 to hospitals, physicians and other “eligible providers” for the purchase and use of EHRs. As a result, EHR adoption among the unfunded providers has lagged behind those who received the federal largesse.
Federally funded drug and alcohol abuse treatment providers, in addition, are governed by a more stringent federal patient-privacy law, 42 CFR Part 2, which requires patient consent before their medical records can be shared with other providers, even for treatment. By default, because many drug and alcohol abuse patients have behavioral health issues, 42 CFR Part 2 has come to protect the records of all three patient groups.
Those protections are far more restrictive than in the Health Insurance Portability and Accountability Act privacy rule, which is applicable to general health patients treated at most hospitals and by most physicians. Since it was modified in 2002, HIPAA has enabled those providers to send and receive patient records without patient consent. These legal differences "complicate integration," the ACO report said.
Privacy protection technology, called data segmentation for privacy, or DS4P, has been tested and is available to deal with these variations in privacy standards, but it's not in widespread use and has only recently been included on a voluntary basis in the next round of federal EHR testing and certification requirements.
CMS data shows that virtually all eligible hospitals (97%) and most eligible physicians (89%) have received at least one federal EHR incentive payment, which signifies they've adopted EHRs. But reported levels of IT adoption among ACO participants in the survey—conducted in August—are lower.
For example, 74% of the ACOs reported using EHRs. Just 57% reported having systems with computerized physician order entry, a mandatory functional capability of an EHR that's been tested and certified as eligible for use in the program.
Other levels of health IT use varied, from 84% with data analytics software, to 61% with case-management software. Fifty-five percent had a data warehouse (typically, a repository that holds clinical, claims and other data types), while 44% have disease registries and population health dashboards.
Only 26% reported using telemedicine, and just 16% were involved in electronic remote patient monitoring.
Care processes to improve patient engagement were also spotty and were far more often focused on treatment of illness than its prevention.
While 65% of ACO respondents said their organizations coached patients to help them better understand what's required for effective treatment, only 37% offered general health and wellness coaching.
Sixty-one percent of ACO participants report their organizations offer patients access to their medical records via an EHR portal, but many portals are view-only, and some only access a portion of a patient's records, the report said.
Most respondents' IT systems (58%) alert patients to preventive-care needs and 48% flag gaps in care, but less than a third (32%) offer secure, two-way messaging between patient and provider. Only 29% can capture patient-generated data.
Not surprisingly, 48% of ACO respondents picked patient engagement as the most difficult activity to perform, higher than quality measurement (40%), care coordination (39%) and chronic disease management (21%).
Last year, the CMS set a target for 2016 that Medicare should use accountable care or other new payment methods for 30% of its spending outside of managed care. The target for 2018 is higher still, 50%.
But just 18% of the ACOs in this survey were assuming “two-sided” risk, in which they face financial penalties for missing performance targets.
A lack of interoperability is not the major impediment to higher risk taking by ACO participants, according to Joel Vengo, vice president and CIO at Baystate Health, Springfield, Mass., a Premier member and survey participant.
“We actually still live in this dichotomy,” said Vengo at a press briefing on the survey results. “Traditional fee-for-service is still the fiscal engine for most healthcare systems” while reimbursements from pay-for-value are lower in comparison, he said. “With pay-for-value, you really have to figure out how to run yourself like a business. You have to be more efficient. It’s really a tough transition to make.”
The percentage of patients covered by value-base reimbursement schemes has not yet reached a tipping point, added Dr. Mimi Huizinga, vice president and chief medical officer at Premier’s Population Health Management Collaborative. But while the CMS targets for value-based payments are “very aggressive,” they’re doable, Huizinga said.
