The directed transformation to Provider Led Health Plans being promoted by the Federal Department of Health and Human Services and the State Health Departments presents a major challenge to the current healthcare industry. The ability of the industry to be responsive to patients, contain costs, and provide patient safety, along with ensuring healthcare quality creates challenges for healthcare information technology organizations charged with supporting this new healthcare model.
The desire to connect health insurers and healthcare providers into a tightly integrated business model that is more efficient, more cost effective, focused on better patient care, and leading to a Value-Based National Healthcare model is commendable. However, achieving such a model is complex, requires diligence, and demands collaboration at all levels, directed at the consolidation and integration of data from multiple database sources and multiple systems. The challenge for CIOs and Information Technology Managers will be to define appropriate data models, process models, and application integration/ interface capability to accommodate the complexity of the data, without compromising the ability to display the data at the appropriate healthcare location. In addition, the integration must interact with the complete application data set to support both healthcare administrative requirements as well as clinical patient centric encounters at the point of care by physicians.
One of the major shortcomings of health plan administrative operations and patient care at the medical practice or medical center has been the seamless integration of data to support both the insurance coverage payment process and the physician care management process. Over the last 30 years, information technology has moved forward in both health plans and managed care systems with claims and in medical practices and hospitals with electronic health records systems; however the integration of these two repositories of critical patient information has not been seamless, real-time, or easy to accomplish. Although the healthcare industry has been working on data standards and application process requirements standardization, the vendor community has been slow to adopt a seamless open way to integrated data from health plan to care delivery location.
"In the new Provider Led Health Plan model, all entities involved need to commit early and diligently engage in collaborative and open communication to make this level of information integration happen."
Now with this new Provider Led Health Plan model, the primary focus is on integrating Population Health Information to be used for better diagnosis, treatment, and overall care management of patient illness conditions, hopefully leading to proactive patient wellness. If this information is critical to deliver quality patient care, then it needs to be available inside of the Electronic Health Record (EHR) that all physicians use to interact with patients. It also needs to be part of the patient information available at the health plan for historical condition management, claims payment, and patient information necessary to determine a patient’s condition overtime for better care management.
In order for this integrated information to be aggregated and used properly for care improvement, sophisticated Healthcare Analytics Systems have been introduced to receive information from multiple sources (health plan, practice, hospitals, laboratories, RX repositories, ancillary facilities, and other care sources) to develop healthcare intelligence. These systems provide important profiling, decision support, and condition intelligence capability to the medical professionals in order to improve care for patients. This is all designed to lead to a higher quality of care and better patient outcomes.
The challenge for the industry is to make this all happen seamlessly as was intended by the supporters of healthcare reform and quality patient care. So given all of these demands for integrated information, healthcare information technology organizations need to consider the following:
• Where do I find the business models and use cases to determine what level of integration we need to address and with whom?
• What level of data do we need to integrate?
• How do we determine which locations, organizations or business entities we need to integrate?
• What is the time frame to make all of this happen and who is driving the process?
• What are the security and privacy implications of the level of integration we need to accomplish?
Once these questions are answered, the CIO must proceed to the following:
• Assess the current state of the data residing in the organization:
-Is there a comprehensive Data Model that is easily understood?
-Is there a complete Data Dictionary readily available?
-Is the data in an industry standard database technology (SQL Server, Oracle, etc.)?
-Is there an API or easily accessible interface to send and receive data to and from other sources?
• Evaluate the ability to integrate with other systems:
-Which Core Administrative Systems?
-Which Electronic Health Records Systems?
-Which Analytics Systems?
-Which Population Health Systems?
• Are there process models to use for data and application integration?
• Do I have the resources or the Information Technology staff that can perform this data and process integration?
The reality in healthcare as in other industries is that too often the CIO and the IT department are contacted long after the business decisions are made. In the new Provider Led Health Plan model, all entities involved need to commit early and diligently engage in collaborative and open communication to make this level of information integration happen.
As all CIOs know, without technology professionals involved early, the best laid business plans can and will fail or delay success. This new Provider Led Health Plan model can create great efficiency and quality in Healthcare, however the CIO needs to be involved in the decision process and will be critical in the overall planning, implementation and success process.