The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.

 

What Data Is Needed to Run an At-Risk Organization?

By Truven Staff
Larry Yuhasz imageThe recent article, “Seven Changes the Affordable Care Act will Likely Encourage in the Medical System,” discusses several new approaches to healthcare that rely on effective management of new data sources and data streams. The ripple effects of the Affordable Care Act will take on many dimensions, ranging from the operational work flow of a health network, to the revenue cycle of those entities going at risk, to the relationship between patients and providers, to the way providers prioritize and spend their time with patients. Given this level of dramatic change, Truven Health Analytics is developing development partnerships with select customers to focus on the required flow of information that will be needed to run at at-risk organization, and the types of analytics and decision support various roles throughout a health network will need to have.

At the center of these activities is the fundamental requirement to establish a single patient record that accumulates knowledge of the patient through each and every encounter. Furthermore, the data collected needs to be organized and acted upon given specific temporal requirements. There is data used for an initial encounter, data for diagnosing, data for monitoring treatment effectiveness, and data for determining overall quality and effectiveness over time. Each requirement has specific conditions, and potentially, limitations, based upon how robust the single patient record is or is not. For example, encounters with new patients where no background information exists will be treated differently than encounters where there is a rich patient history of information. Likewise, encounters with healthy patients may provide the opportunity to collect new data insights into behavioral measures that can be used to keep them healthy, whereas patients with chronic conditions will likely require insights collected related to improving compliance to care guidelines.

In many respects, we may see a future where each encounter has both a patient care and an information care component with it. In fact, patient care and the required work flow is intimately connected to the information gleaned from diagnosis and the eligibility and payment and risk requirements the encounter triggers.

Larry Yuhasz
Director for Strategy and Business Development

Shifting the Data-Sharing Mindset for the At-Risk Healthcare Environment

By Truven Staff
Larry Yuhasz imageThe shift from fee-for-service (FFS) to at-risk reimbursement also represents a shift from siloed data sources and facilities to physician-driven networks that need to be connected with patient-centric decision support and work flow applications. In the FFS world, health systems and health plans often thought of patient data as a strategic asset to help recruit and retain both physicians and patients to their networks and services. Yet, in the at-risk world, the more data available about the patient, the better the ability to manage risk and coordinate care. The change in mindset from controlling patient data to allowing it to flow freely (albeit, securely) across networks is a radical transformation in the U.S. healthcare system. The three key barriers to overcome are business model, proprietary data formats and governance.

At the business model level, as health systems, providers, and payers form new at-risk arrangements, they need to under gird those arrangements with the relevant flow of administrative and clinical data to manage performance and risk. Health plans that have been reticent to share claims data need to shift gears both culturally and operationally to help the new provider-driven networks understand costs.

In terms of format, the Federal government has been trying to stimulate interoperability standards through the ARRA HITECH roll out, but many vendors (particularly EMR vendors) have been fighting back to defend their proprietary data formats. As the volume of at-risk contracts grows, new at-risk entities will not be able to function without some form of interoperable gateway to share and receive patient data. So that means that EMR customers will be the ones to request and implement interoperable gateways from their vendors. And if they continue to resist, there is a new generation of interoperability platform vendors that will fill the need.

Finally, from a legal perspective, no one entity actually “owns” the patient data. The patient owns his/her own data. Yet this creates a quagmire of governance models that is bogged down in consent management policy and privacy mechanisms. If patients do not allow an at-risk network to see their data, the network cannot optimize performance. So we may see a new market dynamic whereby network participation requires upfront patient consent to data sharing (an opt-out consent model).

Larry Yuhasz
Director for Strategy and Business Development

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