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Leveraging Operating HIEs for Accountable Care

image of microscope looking into test tubes

IT infrastructure for managing ACO operations and managing lives under "shared risk" is going to be a big challenge for most organizations. Connecting to regional HIEs may play an important role in addressing this challenge.

For ACO participants to effectively implement care coordination strategies, reduce operational costs, and meet quality performance requirements, they need to be able to access high-quality data from a number of sources, including:

  • Claims data from Payer (e.g. Medicare) for lives being managed
  • Pharmacy/ medication data from PBM
  • Lab result data
  • HIE data – helping receive integrated data from participating providers – both ambulatory and acute

HIE implementations have been one of the important thrust area for the industry over last few years. Today, there are close to 67 live Public HIEs and close to 161 live Private HIEs. Vendors in the HIE space have spent significant time and resources in unifying data feeds from participating healthcare organizations. Regional operating HIEs become a very rich source of patient data for ACOs and ACO participants. For example, outpatient visits, inpatient visits, diagnosis codes, procedures, continuity of care records, discharge meds, problem lists, immunizations, etc.

HIE data-sets, when aggregated, can effectively and consistently support number of care co-ordination use-cases, such as:

  • Look for BP values for patients who are diabetic and schedule them for office visits
  • Identify list of patients who have not yet taken a flu shot in the current season
  • Create cohort of patients with co-morbid conditions, identify 20% of the patient who are cost drivers and use the list for intense care management / disease management programs
  • Look for patients who are on specific medications and look for opportunities to reduce costs / improve treatment
  • Identify physician prescription and referral patterns, to reduce network leakage

With the advent of standards such as ICD-9/ICD-10 (diagnoses code standards), CPT (procedural code standards), LOINC (lab reporting standards) and HL7 (transaction standards) etc. being adopted by Industry and more specifically HIEs, we see several opportunities for ACOs to collaborate with both private and public HIEs to get data for consented patients.

There are obvious challenges that need to be addressed from Privacy issues to Terminology normalization - but the upside for all parties can be substantial. This can also be an interesting opportunity for HIEs to monetize their investments in technology and implementations.

We at CitiusTech are looking forward to developing ideas and solutions around some of these very exciting opportunities.


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