Empowering ACO Success with Integrated Analytics

Transcription

1 APPLICATIONS A WHITE PAPER SERIES IN THE BACKDROP OF THE SEMINAL PATIENT PROTECTION AND AFFORDABLE CARE ACT, NEW MODELS OF CARE DELIVERY, SUCH AS THE ACCOUNTABLE CARE ORGANIZATIONS (ACOS) HAVE EMERGED AS AN ATTEMPT TO TAKE US HEALTHCARE CLOSER TO THE ELUSIVE GOAL OF VALUE-BASED CARE DELIVERY FOR PATIENTS. THE SUCCESS OF THE MODEL HANGS PRECARIOUSLY IN THE ACO S APPROACH, AND THE ABILITY TO ACQUIRE AND ANALYZE DATA COHERENTLY TO BE ABLE TO TAKE DECISIONS ON COST AND UTILIZATION FOR DRIVING AFFORDABILITY AND QUALITY. THE PURPOSE OF THIS WHITE PAPER IS TO EXAMINE THE STRATEGIC CHALLENGES AND OPPORTUNITIES THAT ACOS OFFER AND THE ROLE OF INTEGRATED ANALYTICS AS A KEY ENABLER FOR THE MODEL. Empowering ACO Success with Integrated Analytics

2 TABLE OF CONTENTS EXECUTIVE SUMMARY ACO AN EMERGING MODEL AND ITS CHALLENGES QUEST FOR AN INTEGRATED ANALYTICAL FRAMEWORK ACO USE CASES: ACTIONABLE INSIGHTS COORDINATED CARE COST AND PERFORMANCE MANAGEMENT: ADMINISTRATIVE AND FINANCIAL TREATMENTS AND DISEASE ADMINISTRATION PREDICTIVE ANALYSIS FOR PATIENT CENTRIC DECISIONS 5 6 MOVING FROM PATIENT CENTRIC TO POPULATION CENTRIC TECHNOLOGY READINESS: CRITICAL SUCCESS FACTORS FOR PAYERS ATOS SYNTEL S PRODUCT CONSULTING TEAM OFFERINGS Executive Summary Accountable Care Organizations as a new model for care delivery is yet another attempt in the reform process and a step towards transforming the healthcare industry - from the traditional fee for service-based care to care that creates value for patients. A broad definition of an ACO encompasses the Payer s development of contractual arrangements with the provider organizations based on the notion of shared savings, other value-based integrations between payers and providers as well as setting up patient centric care programs. This definition enables us to explore the challenges and opportunities in this new model that requires a very different mindset and capability on a multitude of domains, from financing to coordinated care delivery to risk and compliance. While creativity is needed to conceptualize these new collaborative business models, IT teams also need to address the key challenges to implement integration among disparate systems to collect, consolidate and process data from multiple touch points. To be a game changer, ACOs must holistically address its data integration and analytics implementation challenges, and transform them into opportunities with quick wins. A future-ready analytics framework that is able to effectively leverage existing investments in core healthcare platforms and the EHR (electronic health records) infrastructure, with major focus on two broad areas of value-based payer-provider integration and real-time actionable insights, has the potential to be the key for the ACO model s success and sustainability S Y N T E L, I N C.

3 2. ACO An Emerging Model and its Challenges As noted by Keckley and Hoffmann, 2010, Accountable Care Organizations are considered a new model of care that will foster change by integrating physicians with other healthcare organizations and rewarding them for controlling costs and improving quality (). While focus remains on achieving clinical and financial integration and/or alignment, a successful integration cannot occur without a pathway to steady, positive medical outcomes. The three major priorities for ACO to counter the barriers that have deterred the expansion of integration are: The idea of bringing together provider practices and organizations (varying in size, specialty or philosophy) to provide a wide range of services, in reality, is not at all simple. The IT challenge lies in standardizing and processing information from heterogeneous systems and then determining analytics that would yield intuitive results. Gathering data from disparate EHR systems across these practices is a challenging task. Building trust across an ACO depends on having a system or framework that pulls diverse streams of data and churns out reliable decision oriented results. Building a longitudinal repository of patient records is also a challenge. This repository includes multiple data points related to claims, EHR, practice management systems, etc. The sources of these data points are heterogeneous and mostly unrefined systems. The challenge is using imperfect, yet the best available data to provide the most accurate overview of patient population, provider cost, referral patterns and other significant information. This information is critical for an ACO to monitor important metrics that measure financial success. The healthcare business landscape is witnessing rapid shifts and vast transformations. A Patient Centric financial structure is emerging, which is shifting from being a service-based to a population-based system, closer to the business model of the insurance company. This approach requires close engagements and collaboration between various providers. To make this a success, organizations must understand the details of payment for different provider types, the system used by CMS to generate targets for bonus payments and other similar challenges. Accountable Care Organizations (ACOs) are described as provider groups that accept Responsibility for the cost and quality of care delivered to a specific population of patients cared for by the groups clinicians. ACOs are bringing broad appeal and hope for the future by improving the coordination and quality of care to patients while reducing the rate of increase in health care costs over time - Shortell, etal Harmonize information coming in from different practices, all of which have different interfaces, and determine what analytics you want to run to produce meaningful results. Develop a repository of "longitudinal" patient records including claims data, information from electronic health records and practice management systems, and data from related forms. Start with practice-level information, including standardized lab results and detailed patient information, if available.

4 3. Quest for an integrated Analytical Framework A new information-driven (integration), evidence-based (longitudinal view) and outcome-driven (actionable insights) model is required to address these goals holistically. By applying analytics on an integrated clinical, financial and administrative data, ACOs can derive meaningful and actionable information. This, in turn, can then be used in decision making and performance evaluations. An Analytics Framework provides and identifies the specific metrics that will be necessary to measure success. These metrics may use data from multiple sources; for example, identifications of common drugs used to treat various diagnoses may require merging medical and pharmacy claims. Hence, the competence of ACO analytics framework to access current (real time), correct, and consistent information will determine efficiency of the ACO. Data Extraction Extracting data from multiple sources empowers organization in a broad spectrum of information and knowledge Data Mining Data Mining and profiling is the next step towards predictive modeling of data based on the buisness need. E.g. - Memeber data profiling, Buying propentisity etc. Optimization Optimize business outcome using different quantitative and qualitative algorithms and heuristics based on predictive modeling for investment optimizaton, budget optimization, plan product mapping optimization etc. Actionable Insight Implant analytics into business developments to achieve real-time paybacks. Refining Excerpt knowledge about response in order to mitigate risk and refine future action. 4. ACO Use Cases: Actionable Insights A systematics implementation of integrated analytical framework will eventually lead to insights that would enable the following business outcomes / models: COORDINATED CARE A coordinated patient care is the emerging care model where all the participants in an ACO are driven to deliver quality outcomes and cost management as a team. This model requires a platform that delivers real-time status and alert information to the operational users of EHR and other systems used for various transactions. To piece together the disjointed and uneven data, the healthcare IT systems need a proper and reliable integration of information across the care system to achieve a 3600 view and synchronized care of patients. An analytical framework helps to determine the accuracy and consistency of communication among providers and other EHR users, enabling ACOs to identify breaks in data transmission, including inaccurate information, miscommunication and skewed information. Integrated Analytics framework estimates the effectiveness and efficiency of various providers workflow and care transitions, as well as identifies gaps in patient care. Close coordination of care can facilitate new payment model that recognizes performance and quality, instead of the volume of the services provided. Close coordination of care benefits New payment models that recognize improved performance and quality instead of the volume of services provided Quality measurement Patient focus COST AND PERFORMANCE MANAGEMENT: ADMINISTRATIVE AND FINANCIAL Analytics can be used to stratify by demographics, health status, and behavior to prioritize, distribute or monitor mediation activity and results continually. As an example, to determine business risk, ACOs can leverage predictive modeling to forecast and identify the most costly patient and derive methods to manage these costs or account for these costs during financial planning. If revenue targets are not met, analytics can help investigate the cause. For an instance, data collected from different care departments and sites can be used to locate higher cost (than anticipated) departments. This intelligence will be helpful in taking target interventions and will improve administrative processes to those hospitals or departments. Both ACOs and payers must use comprehensive cost and performance information for fiscal management to negotiate more suitable contracts based on changes in therapeutic service utilization and patient outcomes that are recorded in clinical, administrative, and financial systems.

5 TREATMENTS AND DISEASE ADMINISTRATION Disease management for patients with chronic conditions that account for 50%-90% of healthcare costs provides a promising opportunity for quality improvement and cost reduction using ACO analytics framework. Analytic techniques enable ACOs to leverage data for identifying standardized approaches and best practices: to evaluate and compare the efficacy of different treatment options, and to optimize the cost effectiveness of specific treatments by measuring costs against the quality of care measures. This evidencebased approach helps ACOs to estimate the comparative benefits of different medical interventions against the potential costs in terms of costs for purchasing new technologies, altered workflows, administrative changes, and others. Analytics framework will also empower Payer organizations with intelligent integration of Claims, Billing/ EHR data from variety of sources to analyze the Pharmacy and Drugs data, to make critical decisions related to drug prescription dates and generate dashboard reports, and to assimilate laboratory results data with the patient status data for regular monitoring of out-of-control conditions and generate dashboard reports. Integrated administrative and clinical databases for analytics offer a rich source of information from which to analyze and report clinical quality measures, calculate risk adjustment and achieve pay-for-performance incentives. PREDICTIVE ANALYSIS FOR PATIENT CENTRIC DECISIONS Predictive analysis helps to develop personalized care recommendations, run effective clinical decision-support systems, eliminate duplicative testing and reach out to patients who are the most likely to require follow-up care. The next stage will involve using analytics to compare an individual's medical history with historical data across the patient population. The analysis of population data will enable clinicians to observe patterns and make recommendations. MOVING FROM PATIENT CENTRIC TO POPULATION CENTRIC Many provider-based decision support systems face a number of challenges to meet population-based analytic demands. Rather than rely entirely on EMR data, the ideal solution is to deploy and leverage an analytic infrastructure that is designed specifically for populationbased healthcare analytics. To provide the highest quality and most cost-effective care to populations, access to multiple types and sources of aggregated data are needed. Aggregated and trusted data will enable ACOs and payer to complete a 360 view of a patient to notify and sustain clinical decisions, forecast patient response to and compliance with treatments, improve outcomes, and control costs. Real-time access to data permits patient information to be combined into administrative and clinical workflows to support clinical decisions at the point of care and improve health outcomes.

6 5. Technology Readiness: Critical Success Factors for Payers To adopt the emerging Payer technologies to support models like ACO, the payer IT needs a strategy that takes them beyond the current compulsions of health care reform. Through strategic initiatives towards health information ecosystem, payers need to enhance their competitiveness and future readiness. The key strategic initiatives will be their focus on healthcare informatics and analytics. Business and Financial Analytics Technologies for Integration Advanced analytics plays a major role for the payer from the claims and financial data management and risk mitigation perspectives. A robust integration of technologies is required to provide a common platform for payer provider convergence, which enables smooth information flow between Payer-hosted EMR and EMR platforms hosted by different providers. Assessing various reports for cost and performance analysis, calculate population risk scores, finding treatment gaps and discovering utilization trends within a Payer organization and ACO are major challenges as these data are distributed across disparate systems. As ACO, the industry-wide trend, starts taking a concrete shape, the technology services dashboard theme will become increasingly salient in sourcing decisions for payers. Payers need to integrate and aggregate all these data from Core Administration platforms (such as TriZetto Facets) into an enterprise data warehouse to enable sophisticated analytics and reporting capabilities. The data warehouse will ensure Health Care Mobility Integrated Communications New Normal in Payer Technology Reports and Dashboard Enterprise Data Warehouse unified communication flow among members and providers, and will permit timely and real-time access to data for ensuring clinical mobility. This single storage of facts (members, provider, claims, billing, payment etc.) is essential to build an integrated analytical framework to empower payers with accurate and reliable information on the QHP population for better offering, positioning and making the payer future ready.

7 6. Atos Syntel's Product Consulting Team Offerings A Comprehensive Analytics solutions designed will help Payers make smarter decisions and improve the overall quality of care. Risk Assessment Fraud Detection Denials Providers Network Network Adequacy Members Risk Assessment Assessing Viability Reports, Portal and Dashboard Cost Management Claims Analytics Care Integration and Collaboration Query Reporting Data Mining Virtualization Knowledge Portal Analytical Tools and Accelerators Integrated Advanced Analytics DW/BI Healthcare Framework Access Validation Data Audit Others ETL And Others Data Authentication and Security Enterprise Data Warehouses and Unified Communication EHR HIE HR Claims Members Data Sources A Strategic Healthcare Informatics Platform for Payers Products & Plans Payments Others Effective care coordination necessitates a platform that delivers real-time status and ready-to-act information from the analytics system to operational and fictional stakeholders of EHRs At Atos Syntel, we offer broad competences on leading Healthcare products/platforms for Core Administration and Care Management such as Facets, NetworX, Care Advance Enterprise [CAE] (from TriZetto), Metavance and HealthEdge. With a dedicated product consulting practice, having over 500 person years of experience and certified product experts, we ensure that our customers derive more value from their product investments, while empowering them with the transformation to a consumer-centric business model. Our unique strategic partnerships with leading product companies have helped us to broaden our breadth and depth of product/platform expertise. We stay a step ahead on evolving architectures and product future roadmaps to help our customers embrace new features / functionalities according to the needs of their business. Under the collaboration with Core Admin and Care Management Platforms, Atos Syntel provides value-based solutions with enriched features such as clinical risk modeling, identification and stratification, patient compliance monitoring, provider cost and utilization analysis and comparison, and cohort analysis.

8 about Us: Atos Syntel is a leading global provider of integrated information technology and knowledge process services. Atos Syntel helps global enterprises evolve the core by leveraging automation, scaled agile and cloud platforms to build efficient application development and management, testing and infrastructure solutions. Our digital services enable companies to engage customers, discover new insights through analytics, and create a more connected enterprise through the internet of things. Our "Customer for Life" philosophy builds collaborative partnerships and creates long-term client value by investing in IP, solutions and industry-focused delivery teams with deep domain knowledge. To learn more, visit us at For more information, visit us at