The Centers for Medicare and Medicaid Services (CMS) recently released the long awaited rules and regulations for Accountable Care Organizations. CMS touts this new patient care paradigm as a shared savings model. However, Providers must clearly take on the risk of payment penalties if they fail to meet all the measures. CMS designed the ACO to accomplish 3 goals; better care for individuals, better population health and reduced costs to CMS. [i] . If the benchmarks are met then the physician will be paid additional revenue for his/her application of medical knowledge and positive outcomes. This is something most physicians want instead of the current system of “chasing” one more fee for service patient visit.
Each ACO will be required to provide medical care to a minimum of 5000 Medicare patients. To add a little uncertainty to an already monstrous undertaking it is at the end of the year that Medicare will choose which of these patients will be accessed for proper receipt of care. In essence all 5000 plus patients will have to cared for at the highest standards and for the lowest costs. As you read through these goals you will see that it will be virtually impossible to accomplish the delivery of patient care and appropriate documentation needed without full emersion into Health Care informatics.
Better care for individuals will be determined by measurable improvements in patient safety, treatment effectiveness, patient-centeredness, timeliness of care delivery, efficiency of operations, and equity of care. There are 65 different performance measures over 5 “domains”. Many of these measures like care coordination across the continuum of health care providers through interfaced information systems are tied directly to the HITECH Meaningful use requirements. Other performance measures necessitate the use of an EHR if for no other reason than the measures are so extensive that a physician or nurse would never be able to consistently (unerringly???) remember the criteria without programmed alerts.
Diabetic care has 10 different measures and congestive heart failure (CHF) has 7 measures of accountability. A physician will need electronic alerts to ensure patients are scheduled on a Best Practice schedule. If the patient doesn’t show up for their appointment then an alert will be needed to let the physician know to call the patient. The call will need to be documented with an electronic time and date stamp to validate contact/attempted contact. Medications and diagnostic tests must be ordered through an eRx component. The tests have to be tracked for completion and the medications trailed to ensure they are purchased and taken as directed. If refills aren’t called in on schedule then…you guessed it…an alert needs to go off. All of this must come with a cross reference medication and diagnostic contraindication alert. A decision support mechanism will be essential to take into account patient multi morbidity and what pathways of Best Practice to follow to obtain the optimum treatment for the lowest cost. If this is sounding way too complicated just wait until you hear what needs to be done to achieve better population health while reducing costs. Well, for your mental health and mine I won’t cover those goals in detail.
More importantly I’ll highlight why the coming of the ACO is so important in the evolution of EHRs and the discipline of Health Care Informatics. Incentivizing healthcare providers and in many ways the general public to start utilizing EHRs is a necessity. This transition to electronic supported healthcare is going to be very difficult for most people and would happen slowly or possibly not at all otherwise. The ACO regulations lay out such essential yet complex goals for healthcare that the people developing and supporting EHRs must advance far beyond their capabilities of today in order to effectively address future needs. Ease of use to include advanced user customization, diverse yet easily understandable decision support capabilities, fluid interoperability, sophisticated speech recognition and lower systems costs all preclude early adoption of most EHR systems. Answers to these problems will only emerge as more people use the systems, discover their flaws or shortcomings and develop the comprehensive solutions. The ACO provides this motivation and momentum in the discipline of Health Care Informatics.
[i]DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services 42 CFR Part 425 [CMS-1345-P] RIN 0938-AQ22 Medicare Program; Medicare Shared Savings Program: Accountable Care http://www.ftc.gov/opp/aco/cms-proposedrule.PDF
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