PDF File: 

HCT3_wp_edwards.pdf

Accenture

Developing a functional EHR is not possible unless the constituents involved work together to determineits scope, how it operates, security measures, means of funding and governance.

Collaboration is increasingly required to make the next set of fundamental shifts in the nation’s healthcare system. For the last decade, significant progress has been made in improving the efficiency and effectiveness of the administrative aspects of care delivery and reimbursement within organizations. Payers have increased automation of claims and care management processes. The ability to exchange electronically the information necessary to conduct common transactions has been, in the main, achieved.

While the healthcare system continues to lag other industries, much progress has been made in digitizing key information within the provider domain as well. EHR systems are in the later stages of adoption in provider systems and there is a real trend toward EHR in the ambulatory setting.While it will take time for the healthcare industry to become as fully automated as, say, the financial services industry, the next “generation” of automation is already upon us.

Over the next decade, the focus will be to increase efficiency and effectiveness of care across organizations. In order to achieve a more integrated, better informed and, therefore, higher quality of patient care, the ability to readily exchange information about care itself needs to be achieved. Regional exchanges are emerging as the vehicle for this exchange.

A regional exchange, or regional health information organization, is a collective term for the system that enables certain information stored in medical records to be made available — in a bounded region or geography — for a predetermined set of constituents to share. These exchanges facilitate improved insight at the point of patient care by facilitating access to EHR data across the variety of care constituents that may be involved in patient care.

Such an exchange is not possible unless these constituents work together to determine its scope, how it operates, security measures, means of funding, governance, capacity for expansion and the process by which to educate and obtain feedback from the community using it. Success must be engineered through a cooperative effort that delivers value to each constituent.

Constituents of the Regional Exchange

The constituents of a regional exchange include all the players in the care management process: patients, physicians, hospitals, inpatient and outpatient services, independent labs and test centers, home health agencies, insurance agencies and others. All groups that would benefit from having insight into a patient’s history — those who would modify or improve patient care based on having access to what happened to that patient yesterday or last week or last month — are constituents. Because of the fragmented nature of the healthcare system, constituents have a poor track record of self-organizing to forge change within the healthcare system (see Figure 1).

Payers are emerging as an organizing focal point — in some communities because they are seeing regional exchange as a way to dramatically improve the quality and reduce the cost of care and in others because they presume they will be “invited” to fund the lion’s share of such efforts. Payers also have, by and large, a much more sophisticated understanding of the infrastructure required for such an exchange. Given that trust levels between payers and (all types of) providers have never been high, there are some challenges inherent in creating the collaboration needed to achieve a regional exchange.

Why Is Collaboration Required?

Collaboration is essential in the conceptualization, development, deployment and ongoing evolution of a regional exchange. Shared vision for how and what the exchange will facilitate is key to success. There is no single provider, payer, lab or patient, for that matter, who is the exchange. Even if an intermediary develops an exchange solution, t is likely that solution will also be the function of collaboration. Issues requiring collaboration include:

• Governance — How will the exchange be overseen? Who, or what body, will be responsible for setting the direction of the exchange?
• Funding and Economic Model — Who will fund the exchange initially and longer term? Will the exchange be self-funding? How will ongoing revenues be generated and managed?
• Ownership — Who owns the solution? It is possible, but unlikely, that a commercial entity will emerge with a solution. It is more likely that a collaboration will yield a solution that may be extended to (and therefore commercialized in) other communities. How each of the constituents “own” the intellectual and other more tangible capital and how they would “participate” in commercializing the solution needs to be addressed.
• Operating Model — Who will manage the exchange on a dayto- day basis including security and access management? How will business processes, policies and procedures be architected, implemented and monitored?
• Deployment and Adoption — How will the exchange be deployed? Who will be responsible for the activities that drive adoption? How will adoption be monitored? What feedback mechanisms will be used?
• Practice Evolution — How could care management processes change to take fullest advantage of the exchange? How will the exchange identify and/or enable providers to understand the impact on care management processes? How will ongoing improvement opportunities for the exchange itself, and corresponding improvements to care management processes, be identified and deployed?

How Can a Productive Collaboration Be Achieved?

While not an exhaustive list, the above highlights some of the more difficult areas to address. Collaboration projects of this complexity tend to require learning, discussion and iterative decision making over a period of time. In such efforts it becomes quite difficult to ensure that decisions build upon each other, rather than decisions continuously recycling. In order to be successful in this type of collaboration, consider these operating principles:

• Make sure the right types of people are involved. There will be technical, operating and business model considerations. Having the right skill sets focused in the right areas is paramount.
• Make sure the people involved are decision makers — or are empowered to make decisions. This will reduce frustration and ensure that momentum can build and be maintained throughout the collaboration process.
• Create a work group mentality vs. a committee mentality. Work groups need to produce deliverables. Groups with a committee mentality tend to have unlimited ability to keep things from happening and no apparent ability to get anything done.
• Form work groups with well-defined scopes and completion criteria. Just because the process is collaborative doesn’t mean that every person has to be involved in every decision.Work groups should be formed to address specific scopes of work relative to the exchange. And as importantly, it should be clear what constitutes the work group being finished. Completion criteria will ensure the work group performs to the requirements and can be disengaged when the requirements are met.
• Structure the collaboration in large blocks of time for specific work products. Structuring eight-hour working sessions once every four weeks, for example, will yield much greater benefit than assembling the same group of constituents for two-hour sessions once a week for four weeks. Ensure that the working sessions are well-designed to achieve needed outcomes.
• Insist upon face-to-face participation. Over time, virtual participation may be able to be accommodated; however, development of trust and group norms needed for success will be achieved more quickly and more firmly through inperson exchange.
• Focus on gaining value as quickly as possible. Start small and do something manageable with a limited scope and, therefore, a limited number of constituents. Beginning with a limited pilot or demonstration project can do a lot to prove out a concept while minimizing expenditures. It can provide the laboratory needed for the human dimensions of the exchange as well as the technical elements. Most importantly, it will likely lead to a larger implementation vision more quickly than those that aim to achieve the entire vision at once.
• Establish a business case and stay true to it during implementation and when measuring success. Regional exchanges are intended to drive value to the healthcare system and, ultimately, to the patient. Defining that value at the outset is the most important step toward achieving it. There will be areas of the business case that are difficult to quantify; however, it will still be important to identify where value is expected and, often, proxy measures can be used as representative of a benefits stream.
• Consider third-party facilitation and support. It will be difficult for any one organization not to be seen as “working an agenda” — even if they are not. This perception alone can cause significant fits and starts to the collaboration. An independent third party can ensure that this dynamic is not an issue for the collaboration. Most importantly, a third party can ensure that each interaction is structured for success, issues are raised and resolved in a timely manner, work groups are coordinated in the context of an overall workplan and timeline and progress is continuous.

Summary

The regional exchange can yield benefits to all constituents of the healthcare system, improving quality of care, increasing efficiency, eliminating duplicate testing and treatment and lowering costs. But in order to provide those benefits, the exchange must be properly designed and implemented, with suitable security measures, a system of governance, a means of funding and methods to encourage and monitor usage. Those design features can only be achieved through collaboration among the patient, provider and payer communities. Collaboration among these traditionally antagonistic groups requires outside facilitation in a setting that allows participants to get to know one another and build trust in each other’s motives. Establishing such a collaborative approach between empowered decision makers who develop and stay true to a business case can deliver a win-win situation for all involved.