Although they first emerged in the mid-90s, Clinically integrated networks (CINs) are now surging as hospitals and physicians navigate the challenging shift from fee-for-service to value-based care. They are finding that connecting to each other is a sound strategy for reducing inefficiencies, improving quality, enabling physicians to maintain independence, and taking on more accountability to manage utilization and the health of populations.
But to succeed -- especially when it comes to care coordination and utilization management -- they need to look beyond the health information exchange (HIE) and the electronic medical record (EMR), IT solutions that have seen wide adoption in recent years as healthcare organizations strive to achieve the goals of the Triple Aim. These solutions have indeed helped CINs improve efficiency and quality -- but must be augmented with additional capabilities to help organizations understand and manage clinical and financial risk, negotiate pay-for-performance contracts (while optimizing fee-for-service revenue) and improve the health of populations.
EMRs have been pivotal to moving healthcare into the era of digitized data, for example, but are designed to optimize episodic, single-patient interactions, storing data captured from patient activity within the hospital or clinic. They are not built at their core for data sharing with other EMRs or other types of systems, or for providing multi-patient views, which are required for integrated networks managing the health of populations. In fact, organizations moving to CINs need four key capabilities that augment EMRs to deliver effective population health management: data aggregation, healthcare analytics, care coordination and management, and wellness and patient engagement.
Before a provider takes on risk, they need to be able to understand their patient populations. They can do this by leveraging patient data stored across the care continuum as a strategic asset. The problem is that CINs often have different IT systems that create separate islands of clinical, administrative and financial data. To complicate matters, while hospitals are affiliated with others in the same network, they don't own or operate them. So it's very difficult for any hospital to control what others implement to ensure integration. That's why data aggregation is critical. CINs must be able to aggregate patient data from multiple, disparate systems across sites, transform it into consistent and meaningful formats and then store that data in a repository, where it can be easily accessed for performing retrospective, near real-time or predictive analytics.
After patients have been identified, CINs then need to analyze, stratify and manage patient populations across networks based on clinical and financial risk, using algorithms to determine patient risk scores. According to industry reports, high-risk patients generate the majority of costs, but approximately 30 percent of the highest cost patients in any given year weren't in the same category a year ago (Institute for Health Technology Transformation. Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare). As a result, predicting the patients most likely to become high risk is crucial to a CIN's success. To accomplish this, they need to account for every patient in a defined population -- those within the health system as well as those outside of it, including patients in need of preventive care, post-acute care or chronic care management.
Next, it's about translating knowledge and insight into action. By understanding their clinical and financial risk, CINs can take steps to manage it. Coordinating care of high-risk patients drives improved outcomes for patient populations. Effective care management and coordination includes leveraging the aggregated clinical, administrative and financial data to identify candidates for program enrollment, addressing gaps in care for managed patients, streamlining population management, and enabling efficient use of evidence-based medicine. This gives CINs the opportunity to improve patient health and facilitate better utilization of resources.
And finally, to be successful, CINs need to promote healthier lifestyles for patients. There are two aspects to this. The first is to engage patients in their health and health decisions as an equal member of the care team. The influence of patient lifestyles and behaviors on health outcomes has five times the impact than that of providers or health plans. Engaging patients leads to smoother recovery from health episodes, encourages patients to choose appropriate treatment options and promotes ongoing self-management. The second aspect relates to measuring and monitoring the impact of these actions on outcomes, cost of care and patient satisfaction once care is delivered. This information should be analyzed so that CINs can bring about continual care delivery process improvements, which will bring about population health improvements and cost savings.
By demonstrating better outcomes at lower cost, CINs have positioned themselves to negotiate with payers and employers in value-based reimbursement markets. To take the next step into population health, however, CINs need to invest in health information technology beyond EMRs in order to effectively manage utilization and the health of populations. Ranging from HIE to analytics to applications for care and utilization management, this technology is necessary for CINs and other organizations to manage clinical and financial risk and succeed in a competitive healthcare market.
Brian Drozdowicz is vice president of population health, Caradigm.