Which Comes First in Accountable Care: Data or Patients?

Posted on September 30, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The headlines are stark and accusatory. “ACOs’ health IT capabilities remain rudimentary.” “ACOs held back by poor interoperability.” But a recent 19-page survey released by the eHealth Initiative tells two stories about Accountable Care Organizations–and I find the story about interoperability less compelling than another one that focuses on patient empowerment.

Certainly, ACOs’ hunger for data is axiomatic. They need to share huge amounts of data internally both to maximize their own resource usage and to treat the whole patient. They need health information exchange (HIE) with outside institutions so they can incorporate insights from them when patients choose to go outside for care. They need population health measures, clinical decision support, and more.

An example of data deprivation can be found in a Government Accountability Office report that tried to figure out why most of the health providers hand-picked by CMS to demonstrate the benefits of accountable care failed to achieve the measly 2% cost improvement set as their goal–even though they produced sterling results on most measurements of improved health care.

The GAO concluded that the problem was lack of data–specifically, feedback on the results of their efforts. CMS possessed the claims data that could be used to generate that feedback, but the data was not exploited. On the CMS side, they took up to two years to crunch the numbers in order to produce actionable feedback. On the provider side, they lacked the tools to do the analysis themselves.

The trade press has routinely released similarly dismal stories about failures to produce high-quality data, to exchange it, and to run analytics. The ACOs were thrown into a data-poor environment characterized by electronic health records loaded with low-quality data (often in unstructured text) and immature standards for health information exchange.

Amazing, then, that a number of advances were reported by the eHealth Initiative report. But the failures dominate. Most notably, “patient safety, cost containment, efficiency, and patient satisfaction” did not improve among the majority of ACOs (p. 15).

This was the other major finding of the eHealth Initiative survey, and one I saw no headlines about. Perhaps the health IT field likes to obsess over data, but I expect that clinicians would give up a lot of population health statistics and other numbers for a closer relationship with the patient. Yet ACOs are not taking advantage of opportunities to involve patients in their own health.

The range of modern tools for empowerment is wide. A shame they are so narrowly deployed. “Few ACOs to date report patient-facing tools that could increase access to care, such as self-service scheduling (33%), phone-based telemedicine (28%) or video-based telemedicine (24%). ACOs are even less likely to offer patients self-management tools such as remote monitoring devices (26%), untethered personal health record (17%), or smartphone apps (15%). (p. 11)

A video connection with a clinician or an app to encourage exercise will probably produce health improvement faster than analytics–although I am a firm believer in analytics as well. Given that ACOs are having trouble finding good tools for data, why don’t they start by turning to everyday tools such as smartphones and using these things to strengthen their impact on patients?

There are risks in patient empowerment as well. The efficacy of most apps has not been proven. Engagement with patients requires more staff time, and this means hiring staff with the right training (and salaries lower than an MD gets).

Patient empowerment and data also intersect, mostly in the area of patient-generated data. But it doesn’t hurt for ACOs to take it slowly, using low-tech means to pick low-hanging fruit and make health a 24/7 concern for the people under their charge. At the same time, they can work over a longer term to add data collection and analysis to their toolbox.