Under the Affordable Care Act, certain provider groups can take on escalating levels of financial risk as they became more accountable for the quality and cost of the care delivered to Medicare beneficiaries.  These Accountable Care Organizations (ACOs) as defined by the Centers for Medicare and Medicaid Services (CMS) encompass three types of Medicare Shared Savings programs — upside risk only, up and downside risk, and advance payment — and the Pioneer ACO program.  All are required to demonstrate that they can promote evidence-based medicine and patient engagement, coordinate patient centered care, and report on quality and cost measures for internal use as well as to CMS.  A number of commercial insurers are also offering similar types of risk-based accountable care arrangements to selected provider groups, whether or not they are engaged in one of the federal programs.  To date, there are over 400 provider organizations engaged in some form of accountable care.

Unlike the capitation models contracted by commercial insurers as Health Maintenance Organization (HMO) products in the 1990s, today’s arrangements emphasize quality and patient-centered care.  They also rely on health information technologies which hold significant potential to enable high value care.  But the promise of accountable care is tempered by a dearth of experience with care-process redesign and culture change and of knowledge about the health information technology (HIT) infrastructure necessary to optimally support health care transformation.  There are many factors that will contribute to the success or failure of an organization in the accountable care environment.  One that will determine an ACO’s success is the presence or absence of a focused HIT roadmap that aligns an organization’s limited resources with its goals and objectives for accountable care.  Without clear guidance in identifying and prioritizing their HIT needs, many provider organizations are struggling to develop their roadmaps.

The Certification Commission for Health Information Technology (CCHIT) — a not-for-profit HIT certification body with an educational mission — recognized that, in the current accountable care environment, something is missing:  a structured approach that would help providers identify the most effective, highest-value HIT investments that would meet their specific needs.  Its Commissioners and a specially convened Expert Advisory Panel (listed in Figure 1 below) therefore developed a publicly available HIT Framework for Accountable Care.   The Framework is designed to serve as a starting point not only for provider groups developing their HIT roadmaps, but also for payers looking to assess and/or complement the HIT capabilities of their contracted provider partners, and for developers designing systems and products to fill the gaps in currently available technologies.

Framework Development

In developing the draft Framework, the Commission started with a set of aims that are specifically important to provider groups:  high-quality care, cost efficiency, and strong customer loyalty. It then defined seven unique but all encompassing high-level business processes that must be implemented to meet these aims effectively:

  • Care Coordination
  • Cohort Management
  • Patient Relationship Management
  • Clinician Engagement
  • Financial Management
  • Reporting
  • Knowledge Management

Each Key Process, as they are called in the Framework, includes a number of specific steps or Functions that outline how that process can operate most effectively.  HIT Capabilities supporting each Function were then identified and listed.  The Expert Advisory Panel was subsequently convened to review, modify, and expand on the work of the Commission.

In addition to further specifying and delineating a more robust version of the Commissioners’ draft Framework, the Expert Advisory Panel recognized the importance of four Primary HIT Requirements, without which an accountable care provider group could not construct a fully functional HIT infrastructure.    These Primary Requirements include:

  • the ability to share health care information between and among various providers (both within and external to the accountable care organization) and patients/designated caregivers
  • data integration from clinical, administrative, financial, and patient derived sources
  • attention to HIT functions that support patient safety
  • strong privacy and security protections

The Expert Advisory Panel also developed a Glidepath which reflects an organization’s transformation along a continuum from volume-based to value-based health care, specifically looking at how professional culture, concepts of quality, cost containment, and patient influence could change as the organization takes on higher levels of financial risk.  The Framework’s Functions and HIT Capabilities were then mapped to the various stages of the Glidepath.

It is important to note there was consensus regarding the non-prescriptive nature of the Framework with respect to what type of technology should be used as long as the data from that technology could be integrated with data from other technologies.  The Framework is also not prescriptive with respect to an organization’s goals or how it plans to meet them.  The Framework, instead, provides guidance for investing in HIT once those goals and intentions are established.  The Framework is a first step and will evolve as experience is gained in the field.  It is also aspirational, including several HIT Capabilities that have yet to be developed or piloted in the field.

Although the Framework is comprehensive, it is unlikely to be a complete listing of all relevant or possible functions and HIT capabilities.  Alternatively, some may find it too comprehensive and wish to include in their own roadmap only a limited set of listed Functions and HIT Capabilities for specific settings and situations.  Care should be taken in this circumstance to review all of the Framework’s elements to assure that all Functions and HIT Capabilities necessary for an integrated system specific to an organization’s needs are included.  As an example, the HIT Capability of a Master Patient Index is listed under one specific Function, Administrative Simplification, but is applicable to others.

While the Framework is designed to support resource planning at the organizational level, the HIT Capabilities are also focused on the needs of individual users as well as organizations.  It is also important to note that the HIT Capabilities are not testable criteria that could be used to certify that specific technologies perform as advertised.  Lastly, we emphasize that, while necessary, a well-aligned HIT infrastructure alone is not enough to bring about the changes necessary for any organization to succeed in meeting its goals for accountability.

In spite of these caveats, we believe that providers, payers, and technology developers will find CCHIT’s HIT Framework for Accountable Care useful.  We also believe that it can provide a foundation for structured discussion among these different stakeholders as well as among policy developers.

The interactive Framework, along with an in-depth explanation of its various elements and a User’s Guide, is available here.

Summary and Next Steps

CCHIT’s Commission and the Expert Advisory Panel present this first consensus-developed, publicly available HIT Framework for Accountable Care as a basis for structured discussion and planning.   The Framework represents a starting point for those organizations wishing to build an HIT infrastructure to support varying levels of financial risk while improving quality, managing cost, changing clinician culture, and including patients as partners in care.  As the delivery systems’ needs become more defined with respect to HIT in the accountable care environment and as HIT continues to evolve, the Framework, too, will evolve over time.   In the interim, we hope this first step will prove useful to all stakeholders, and we invite comment and feedback on all of its aspects.