tions should consider implementing them even if they have yet
to implement a full EHR system. 3
Aggressive case management is a proven method of reducing the cost of care for patients with chronic diseases. 4 Disease
management programs cannot be effective unless patients with
chronic diseases such as asthma, diabetes, or hypertension can
be identified and tracked for follow-up and intervention.
CMS proposes providing physicians with patient-level service
and demographic information to help them avoid duplicate diagnostic testing and adverse drug interactions. Physicians may
use these data to identify patients that are good candidates for
patient management programs, and the information may serve
as the basis for problem lists.
It is not clear if physicians will be provided with the necessary
tools to synthesize and analyze the data. HIM staff with strong
analytic skills can be critical in ensuring the accuracy of registry information and translating the service history data into information that allows an ACO to manage the care of its patient
populations.
An additional risk for ACOs is the fact that beneficiaries are
not required to enroll in a particular ACO. They may seek treatment from any ACO, and any reductions in the cost of their care
may be distributed among all ACOs involved in their care. This
is one of the key differences between an ACO and an HMO or
Medicare Advantage plan.
In an HMO, beneficiaries choose a plan and become a member. They must seek care within that HMO’s network or be subject to additional co-payments. Since beneficiaries may seek
care from a number of ACOs, the cost savings from one ACO
may be offset by a cost increase by another. This puts the ACOs
projected shared savings at risk.
Quality Measurement and Reporting
As noted, ACOs will be required to report quality measures,
which they will do in a form and manner defined by the HHS
secretary. CMS has proposed 65 measures for use in establishing quality performance standards for the first performance period. Measures for the remaining two years will be discussed in
future rule making. CMS expects to expand the measures to include other highly prevalent conditions and care settings, such
as hospital, home health, and nursing home.
CMS plans to calculate performance results for the first program year via survey instruments, claims data, and the Group
Practice Reporting Option (a CMS data collection tool). In subsequent years, CMS proposes to expand measures reporting to
include EHR-based mechanisms. For example, by the second
performance year, CMS proposes to develop the capability of
the Group Practice Reporting Option so that it interfaces with
EHR technology and allows EHR data to populate the reporting
tool.
ACOs must assess data capture, reporting, and performance
requirements associated with each performance year and ensure the appropriate technology and workforce are in place.
Clinical Documentation and Health Record Management
All organizations and providers need accurate and timely information to efficiently and effectively treat their patients and
enable high-quality, patient-centered care. CMS recognizes the
importance of technology and information exchange as part of
the ACO care coordinating and patient-centered criteria.
CMS has proposed that ACOs will be required to have processes in place to enable the electronic exchange of information, evaluate the health needs of assigned populations, develop individualized care plans for targeted populations, allow
beneficiary engagement and shared decision making and allow
beneficiaries access to their health record.
Detailed clinical documentation and health record management practices will be critical to the success of an ACO.
Information Sharing and Patient Privacy
ACOs and their suppliers are covered entities under the HIPAA
privacy rule and are thus subject to its requirements. An ACO
may be a HIPAA covered entity if it conducts electronic transactions for claims, eligibility, or enrollment.
In addition to the HIPAA guidelines, CMS is proposing to require an ACO to enter into a data use agreement in order to participate in the program. Under the agreement, the ACO would
be barred from sharing Medicare claims data provided through
the program with anyone outside of the ACO.
This will be considered a compliance requirement as a condition of an ACO’s participation in the program. If the ACO does
not comply with this requirement it will no longer be eligible to
receive data, and its participation will be terminated. ¢
Notes
1. Centers for Medicare and Medicaid Services, Office of Inspector General. “Medicare Program; Medicare Shared
Savings Program: Accountable Care Organizations and
Medicare Program: Waiver Designs in Connection with
the Medicare Shared Savings Program and the Innovation
Center.” Federal Register 76, no. 67 (April 7, 2011). http://
edocket.access.gpo.gov/2011/pdf/2011-7880.pdf.
2. Ibid.
3. Sacks, Lee. “Clinical Integration: The Foundation for Accountable Care.” 2011 HIMSS Convention Proceedings,
February 2011.
4. Fireman, Bruce, Joan Bartlett, and Joe Selby. “Can Disease
Management Reduce Health Care Costs By Improving
Quality?” Health Affairs 23, no. 6 (2004): 63–75. http://con-
tent.healthaffairs.org/content/23/6/63.full.
Susan White ( susan.white@osumc.edu) is clinical associate professor of
health information management and systems at Ohio State University.
Crystal Kallem ( crystal.kallem@ahima.org) is director of practice leadership;
Allison Viola ( allison.viola@ahima.org) is director of federal relations; and
June Bronnert ( june.bronnert@ahima.org) is director of professional practice
resources at AHIMA.
