As regular readers probably already know, I've been hiding out for several months now, getting up to speed in my new position as Chief Technology Officer at Cielo MedSolutions LLC. It's a natural next step for me, because Cielo is commercializing a University of Michigan Health System spinoff technology with which I was intimately involved in my previous position as a research informatician.
The spinoff technology was ClinfoTracker, a relatively simple and straightforward prompt and reminder system for primary care providers (PCPs). Now it has evolved into Cielo Clinic™, a clinical quality management system that can dramatically accelerate a practice's ability to participate in pay-for-performance (P4P) and pay-for-reporting (P4R) programs. Participation in P4P/R programs translates directly into additional revenue for the practice, and it does so by facilitatinbetter quality care through delivery of evidence-based medicine in situ in the PCP-patient encounter.
There are other applications that support P4P/R participation, of course; some of these also provide alerts that are crude equivalents of Cielo Clinic's prompts and reminders. By "crude"
Cielo's compelling advantage stems from its focus on capturing and using clinical data rather than relying on billing data to drive its rules engine. Rather than rely on ICD-9, the standard for coding problems in the US third-party payer world, Cielo Clinic employs ICPC and ENCODE, which are specifically designed for the primary care setting. Billing data has been shown to be unreliable for quality management in primary care.
Moreover, Cielo Clinic tracks clinician's response to the prompts. This ensures that, for example, if a physician has already advised a patient to undergo a colonoscopy based on a prompt driven by current clinical guidelines for colorectal cancer screening, and the patient refused, that prompt will not reappear for one year (or at a longer or shorter interval of the clinician's choosing, based on their knowledge of the patient).
We've been working on a new product that will soon become manifest in the marketplace, focused in part on the obvious buzzword of the day: Meaningful Use (MU), the benchmark the HITECH Act will use with its implications for direct patient care providers of $44K in incentives to adopt health IT.
However, we see HITECH and MU as blips on the strategic radar. The real opportunity -- and challenge -- in primary care health IT is in the development of Accountable Care Organizations (ACOs).
Lisa Bielamowicz, MD, Managing Director with the Health Care Advisory Board, the research division of The Advisory Board Company (ABC), recently posted a video entitled Keys to Success With Accountable Care Organizations on the MedPulse Business of Medicine newsletter from Medscape (free membership required to access). It's an 8-minute video that gives some good insights into how PCPs, their local hospitals, and the specialist practitioners with whom they collaborate can work together to improve patient care while reducing costs under the aegis of ACOs.
PCPs are at the nexus of the ACO and critical to its success, but there are obstacles that must be overcome, not least of which is that PCPs don't have a lot of time to spend figuring out how to work with ACOs:
Enhanced primary care is going to be the backbone of the ACO. We're going to need our PCP practices to be able to not only do the great job that they are doing today in delivering high quality care but to provide more comprehensive care, enhanced chronic disease management, coordinate care with other providers across the continuum, and really engage patients in being active care partners in a way that is new and more energized than we ever have before.
Unfortunately, primary care physicians are busy. They are already working long hours within their practices today, and if they alone as physicians did all of the things required of them, if they develop a medical home delivery model, they'd be spending 22 hours a day within the 4 walls of the practice. Clearly that is not something that's going to be sustainable.
Dr. Bielamowicz identifies two key imperatives for PCPs to make ACOs work for them: identifying and engaging with the right partners (including but not limited to hospitals, health systems, specialists); and engaging payers to ensure the financial incentives align with the work needed to make the ACO fly. These are human social and political endeavors, of course, but there are a number of ways information technologies can facilitate these endeavors, and especially to aid in their implementation in the real world.
ACOs and CSCW
I've spent a lot of time and energy, both work and education-wise, in the field of Computer-Supported Cooperative (or Collaborative) Work (CSCW). To me, ACOs are highly reminiscent of the class of computer applications we call Groupware. Lotus Notes is probably the archetypal entry in this market space, but there have been many others since, all of which met with varying degrees of success in actual field deployments.
Back in the 1990's, Jonathan Grudin, Wanda Orlikowski, and others identified some of the thorny problems involved in getting groupware applications deployed. Among these are disparities in work and benefit; failure to achieve critical mass; disruption of social processes; and the need for careful planning and introduction than intuition would suggest. I believe ACOs will face many of the same challenges.
The ACO is not a computer application, but one thing is clear to all concerned: a key component that will either make or break ACOs is the information technology and communications infrastructure that is employed.
Like ABC, we at Cielo believe that quality metrics are an important component of the ACO's success, and one that can be best enabled through the ICT infrastructure. We are actively engaged in the the development of products and services that will empower PCPs to participate in ACOs efficiently and effectively, delivering increasing quality in patient care with the same or lower level of effort and the same or higher level of profitability they can achieve today. It is a win-win-win scenario, with the participants, patients, and payers (especially the taxpayers) all benefiting.