Wednesday, June 12, 2013

Health Information Exchange and Accountable Care




Are HIEs Ready for Accountable Care?

This is a very interesting question.  HIEs were originally proposed long before the Affordable Care Act was law.  Their concept was to allow for  interoperability by harmonization and standardization of disparate EMR vendors.

The Accountable Care Organization is conceived to improve reimbursement paradigms, improve outcomes and to coordinate care among providers.

EMR and HIE came along long before the ACO was a concept.  The ACO in fact is not a reality in many places. Development costs, organization and implementation are a complex process.

I have not seen a concept of how HIEs would interact with ACOs. Technically all things are possible.

One of the centerpieces of the effort was support for the development of Health Information Exchanges. The government threw $564 million into the effort to create statewide HIEs, and some states followed suit with their own financial support.

But the big question facing the industry is what role, if any, HIEs can and will play in supporting the newest federal idea: accountable care organizations. As of February 2013, there were more than 250 Medicare ACOs, according to the Centers for Medicare and Medicaid Services; in a Health Affairs article published in February, David Muhlestein, an analyst at research/consulting firm Leavitt Partners, pegged the total number of ACOs at 428.

ACOs are credited as booming, and as of right now, there seems to be enough HIEs to support them. However, the future of HIEs is extremely murky due to the problem that has plagued the information exchanges since their conception-financial sustainability.

Most of the ACO effort has not been in terms of management, but the complexity of formation.   There are few operating Accountable Care Organizations working. Some that have been formed and operating are large health systems already operating as a single business entity.

The vast majority of medical practitioners and small hospitals function independently and have no contractual agreements with each other, a fundamental requirement for operating an ACO, to manage reimbursement, measure outcomes, and plan.

Stakeholder advocacy group eHealth Initiative assessed the state of HIEs in the United States in 2012 and identified 222 public and private HIEs, down from 255 in 2011.

A total of 161 HIEs responded to the organization's annual survey, the results of which highlight a big problem: Only 29 HIEs reported themselves as being financially self-sustaining. Ninety-three HIEs in 2012 said they were "highly likely" to be in business in three years, and 64 of those believe they will be financially sustainable within the next three years.

However, nearly half of those optimists currently depend on federal funds as their primary revenue source. And the $564 million in federal funding awarded to state HIEs under the HITECH Act stops in October 2013, with currently budgeted state funding sources expected to dry up by March 2014.

Very few HIEs are ready. The  eHealth Initiative survey also indicates that ACOs likely won't find the kind of data networks they could pay to piggyback on: Only 24 HIEs in 2012 reported being able to offer value-added services such as advanced data analytics, quality reporting, clinical decision support, and PACS reporting, all of which are services needed just as much by value-based programs as the actual exchange of data.

But too many HIEs are little more than a fax machine, sending a PDF-based Continuity of Care Document or medical image to a fax or into an EHR, and a surgeon can't operate the clinical decision support functionality of an EHR on information in a PDF.

Health Data Management also discusses further unknowns regarding the relationshiop between an ACO and a HIE.

Smoke and mirrors, cannot substitute for building ACOs on top of already inadequate Health Information Exchanges.


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