Community health centers have gotten considerably more complex – both clinically and operationally – in the past 5 or so years. On the one hand, the amount of operational, clinical and demographic information needed to run a health center has increased and the need to generate, analyze and make decisions using this data has gotten more and more critical. On the other hand, the amount of information now available for analysis and issue evaluation allows for a broader and more sophisticated range of approaches to decision making. Health centers are awash with information – the question is how it can best be used to improve outcomes and operational efficiency, so that information becomes truly part of the solution.
Several vehicles provide a pathway for CHCs to collect, analyze and apply information. The first of these is meaningful use, Stage 2 and Stage 3. Meaningful Use criteria emphasize information use, sometimes in new and critical ways. CHCs have a need to exchange and mine information across provider locations, if for no other reasons than MU Stages 2/3 require health centers to demonstrate capability with respect to clinical decision support, care transition facilitation, and public health reporting. One of the new criteria for Stage 2 is the care transition requirement that states: “The EP/EH/CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides summary care records for each transition of care or referral.” This summary must be provided via certified EHR technology. There are also requirements for providing patients access to their health care records, as well as for submitting data to immunization registries and public health organizations. Stage 3 also proposes closed-loop referrals, where the consulting provider must send information back to the initiating provider – often a PCP at a health center.
As evidenced by the number of PCAs, large CHCs and HCCNs that are planning or executing on data warehouse and analytics projects, CHCs have begun to look for additional ways, beyond MU compliance, to meet these requirements. Some CHCs are looking to health information exchanges (HIEs) to potentially provide this capability along, of course, with core exchange functions. HIEs may create a robust opportunity for aligning the capabilities needed to improve clinical and operational outcomes. As HIEs seek to create sustainable business models and reframe the value they offer to participants, many have begun to offer access to DIRECT messaging and analytic capabilities in addition to core exchange services. The analytic features often include risk calculations and cost-per-patient metrics. These additional analytic capabilities are accompanied by organizational, technical and financial sophistication. Inclusion in an HIE is one way that health centers can acquire this set of capabilities without having to develop it internally or independently.
Another pathway is through participation in an accountable care organization (ACO), and some CHCs are now looking to participation in ACO) as a means of acquiring the new data-sharing and analytics capabilities needed to participate fully in a risk-based environment. How are HIES, ACOs and Meaningful Use of healthcare delivery and certification related today? And what does their convergence suggest for health centers?
A PwC survey found that 50% of the 93 NCQA criteria for accreditation of an ACO overlapped with Meaningful Use metrics. The same PwC survey found that in addition, among the responding healthcare organizations, 58% expected to participate in an ACO through an HIE. Further, PwC determined that with each of the three Meaningful Use stages, increasing more of the features and criteria for ACO participation were met so that an organization that fully qualified for Stage 2 Meaningful Use was probably qualified for ACO participation as well. By Stage 3, a health center would be:
- Providing health summaries for continuity of care (S2)
- Populating PHRs (S2)
- Making close to full use of CPOE (S2)
- Using point-of-care clinical decision support (S2) & using clinical decision support for national high-priority conditions (S3)
- Accessing comprehensive data from all available sources (S3)
- Generating dynamic/ad hoc quality reports (S3)
- Doing real-time syndromic surveillance (S3)
- Using clinical dashboards (S3)
These core Meaningful Use elements are also key attributes of highly functional ACOs.
So why is this important for Health Centers? Most of the data on CHC participation in HIEs today is anecdotal. I work with two HIEs very closely today; one is a Beacon Community in Southern California and the other is in rural Oregon. Both of these, as well as most of the other HIEs I know of, include FQHCs as well as other types of health centers as participants, but the extent of their participation is not always clear. Health Centers can make use of the connectivity, either through NwHIN CONNECT or increasingly through NwHIN DIRECT secure data transfer platforms, to address Stage 2 & 3 Meaningful Use criteria for collaboration and care transition, patient connection, external reporting (immunization registries, public health) quality metric measurement and reporting and report generation. The collaborative and connection-based aspects of Meaningful Use become increasingly more important in Stage 2 & Stage 3.
Health centers may benefit further from the large increase in potential providers through consultation by participation in an HIE. The HIE will likely have the infrastructure in place for teleconsultation and in any case, will be able to share clinical and demographic data on patients with the CHC through conventional means (EHR integration, electronic & conventional referral processes, etc.).
In addition, CHCs can make strategic use of the trend as the HIEs in which they participate evolve into &/or become associated with ACOs. The development of innovative analytic capabilities using the ACOs’ expertise goes beyond Meaningful Use and could potentially include analysis of:
- individual & group care patterns & results to improve quality of care & clinical performance
- population health trends
- health disparities & the impact of care interventions
- many others
CHCs may get some of this analytic capability through other organizations such as PCAs or HCCNs, but ACOs are, of necessity, focused on this capability.
It’s not so much that HIEs are looking to become ACOs as that ACOs, by virtue of their programs and mission, need to have the connectivity, capability and physician affinity model that HIEs provide. One of the issues for health centers (and healthcare organizations in general) is that ACOs and HIEs may become “closed worlds” where providers only interact with providers from within the exchange
In summary, CHCs’ need to access and utilize both clinical and non-clinical information that has grown in new and in some cases unanticipated ways, pushed by the latest stages of Meaningful Use criteria and by the need to improve outcomes as well as clinical and operational efficiency. Participation in an HIE provides certain advantages and capabilities for the necessary connectivity and data access for CHCs. As HIEs evolve, driven by the need for sustainable business models, they offer additional function for their participants, including new types of connectivity such as NwHIN DIRECT and new analytic capabilities. This pushes them toward ACO participation, either by becoming an ACO or aligning with one. CHCs that are in an HIE that moves in this direction get additional benefits and leverage related to the risk and revenue sharing in the ACO model and to enhanced analytic capabilities made available through ACO participation . A CHC that is at Stage 2 Meaningful Use or higher is potentially ready to take advantage of this HIE-ACO alignment.
Of course all this comes with new requirements for the health center in terms of training, new clinical and operational workflows to be consistent with HIE & ACO patterns, and possibly even new personnel and IT infrastructure needs. It appears, however, that the advantages outweigh the various costs and adjustments needed to be part of this evolution.
David Hartzband, D.Sc. is Director of Technology Research at the RCHN Community Health Foundation.