Thursday, July 14, 2011

What ACO Features Are Needed in an EHR?

Most EHR systems are based on strategies that predate accountable care organizations (ACO) and Certified EHR standards.  The key EHR requirements for ACOs are the ability to electronically exchange patient information, support provider collaboration, and monitor patient care.  The EHR focus to date has been on creating patient exam notes and specifically meeting the Evaluation and Management documentation standards.  Most EHR products do not adequately accommodate the operational or management needs of the ACO structure.

Many Certified EHR products have structural designs that will not address ACO patient care needs.  The active management and tracking of patient service issues and the maintenance of referential integrity for patient care is an area that requires dramatic changes to many EHR products.  As important the expanded use of electronic exchanges necessitates auditable tracking of information sources as well as activities associated with those incoming and outgoing transactions. 

Certified EHRs can accept electronic transactions such as the Continuity of Care Record (CCR), but mostly do a poor job of tracking CCR related clinical activities.  For example, the incoming CCR may trigger some clinical activities that will be reported back to the CCR source provider as well as tracked internally as the trigger for the follow-up patient service items.  In most EHRs, each event is treated as a discrete item that is not related to the CCR or subsequent events.  The lack of life cycle management and tracking tools makes management of ACO relationships and quality assurance difficult, if not impossible.

The lack of tracking tools could pose a number of patient service and medical; professional liability issues to the ACO as well as participating ACO providers.  For example, the lack of tools to track appropriate clinical and patient service responses would make it impossible to monitor ACO activities and standards.  In the event of a compliance audit or a medical professional liability discovery process, the EHR would not adequately reflect the due diligence for the patient situation.  For example, many EHR products do not consider workflow messages part of the patient medical record.  Such workflow messages may be a necessity for collaboration on care issues triggered by an incoming CCR.

ACOs require several components that are not typically found in EHR products today:

Patient Service Tracking –

The patient service tools in many EHR products lack adequate management and standards monitoring tools to assure adequate provider response and handling.  In some cases, the lack of referential integrity within the EHR makes patient service tracking impossible.  For example, a number of EHRs require a patient service item to be recorded in three places: the exam note, the order feature and a message for staff.  You cannot verify completion of a patient service item from the exam note and the order frequently is not connected to the exam note.

ACO oriented patient service features track the relationship of all events triggered and derived for the patient visit as well as contextual tools to manage the lifecycle of patient service events.

Collaboration Within the ACO –

Effective and efficient collaboration on patient care is a strategic necessity for any ACO.  In most cases, CCR transactions and other electronically received information are magically inserted into the EHR without an effective or adequate audit trail of the source transaction or response.  Other ACO related exchanges with other providers are typically entered as a miscellaneous message without context or connections to the ACO relationship.  Indeed, in many EHRs, the person who receives the information and posts the information to the patient chart is identified as the audit source.

An ACO’s EHR must clearly identify the source of EHR information from ACO partners as well as track the state of such information.  For example, the incoming information could be pending an action, completed, or awaiting further activities.  As important, links should be maintained to provider activities related to the incoming information.  ACO participants will also need effective management tools for exchanges of information as well as the ability to focus on particular ACO related activities or participants.  For example, the provider may want to examine the outstanding patient service items sent to a particular ACO provider.   

Electronic Transaction Workflow –

A Continuity of Care Record (CCR) structure is used to transmit patient health summary from one EHR to another EHR over a network such as a Health Information Exchange.  However, many EHR systems discretely create the CCR in support of Meaningful Use, but fail to track the lifecycle of the CCR.  For example, a CCR transmission could be in support of a treatment plan item from a doctor.  From an ACO and practice perspective, the transmission of the CCR is part of the patient service process and requires tracking tools at the sending and receiving points.  Unfortunately, most EHR systems do not adequately track the status or source of incoming information from other parties.  For example, the ACO and practice will be interested in the form of the original incoming information as well as changes to the information and activities triggered by the incoming CCR transaction.

ACO participants will be interested in electronic transactions that are related in the much the same way that we are interested in the relationship between an authorization, claim and explanation of benefits in medical billing systems.  For example, we may want to be able to track the CCR into the EHR and the resulting patient visit note, as well as the transmission of the visit note to the source of the CCR.

EHR deployment and use is a necessity for any ACO and ACO provider.  However, the assumption that an EHR will adequately support the collaborative structure of the ACO or the exchange of electronic information among ACO providers is not a good strategy for any ACO or ACO participant.  ACOs and ACO providers need to seriously review and examine the underlying EHR features to assure that the EHR can support ACO related life cycle activities as well as provide management with tools to monitor ACO relationships and performance.  

© Sterling Solutions, 2011

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