13 ADVANCE FOR HEALTH INFORMATION PROFESSIONALS / ACOS SEPTEMBER 2016 platforms allow all members of the care team to access patients’ full medical records and other key data (i.e., social determinants of health) for better quality, more proactive care. • Preventive care (e.g., screening mammograms) can occur proactively instead of retrospectively when the right systems are in place. Instead of patients making a yearly appointment with a provider for a mammogram, the testing is done prior to the appointment with the provider. Proactive care models also include access to data that helps avoid unnecessary duplicate medical testing and provider appointments. • Care coordination and transitions of care will be more important than ever: More sophisticated data analytics allow providers and care coordinators to better (and more quickly) identify members of their populations who are high risk. Instead of waiting for payers to identify patients at risk weeks or months after a qualifying event, providers can leverage analytics to build their own cohorts and flag them proactively for real-time interventions that lead to better outcomes. • Patients who are ready to be discharged and have a high risk score based on data analytics can be placed on a care pathway before they leave, with follow-up appointments and calls already scheduled. Emphasis is placed on medication knowledge for adherence and addressing social factors that may affect patient outcomes (e.g., a lack of transportation to a follow-up appointment). • Documentation requirements may increase, but technology will make it easier: With so many care models emerging, documentation will continue to be important from an accountability perspective. Optimally integrated solutions will align quality measures that have crossover across care models so providers will simply document what they are accountable for and move on to the next patient, without worrying about what documentation ties to which care measure. • ACOs and other healthcare delivery systems can gain flexibility by using dynamic registry capabilities and workflows that grow with them to manage differing shared savings contracts or other risk-bearing relationships. Innovative specialty applications running on top of open-data platforms allow quick action on quality measure reporting that requires pulling data from many disparate provider groups in a short time frame. This capability is especially important when payers don’t provide details on their updated reporting requirements until shortly before they are due. Making the Triple Aim a Rality With the evolution in care delivery and payment models, many transitions will need to occur within healthcare organizations related to workflows, governance and change management. Ultimately, technology is the enabler to support it all. The technology that enables all of these changes must be flexible and adaptable so that it, too, can evolve along with the care models. Healthcare organizations that are equipped with the right technology to change—whether that change is driven by consumer, regulatory or market demands—will drive the care of the future. These organizations will succeed in moving the healthcare community towards the Triple Aim. Cheryl McKay is chief nursing officer, Orion Health. Providers and payers also need ready access to genomic, social, environmental and behavioral data sets to drive effective patient care plans.
Advance for Health Information Professionals • January 2017
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