Clinically integrated networks (CINs) consist of like-minded healthcare professionals that engage physicians, connect providers and hospitals, share data, improve patient care, and decrease overutilization. A CIN that aims to succeed under value-based principles requires several components to support operational changes to members’ day to day and technology-based resources. In Lightbeam’s experience, to promote enhanced quality of care and cost efficiency, clinically integrated networks require:
- Complete health records
- Bi-directional data integration to support a physician affinity strategy
- Varied risk stratification methods
- Referral management capabilities
- Unified care management practices
Complete Health Records
A CIN needs to create a holistic view of their patients using data from clinical and claims systems. The comprehensive data creates a foundation for effective population health management. Since a single electronic health record (EHR) does not offer the data necessary, CINs need to put the infrastructure in place to not only capture data from disparate sources but normalize it as well. The infrastructure can be deployed through an enterprise data warehouse or a health information exchange (HIE). With these solutions in place, CINs can begin the journey of analyzing and stratifying data to share critical insights with providers within their network. Such insights might include gaps in care, coding opportunities, or alerts for when patients within their system are admitted or discharged from hospitals.
Bi-Directional Data Integration to Support a Physician Affinity Strategy
A physician affinity strategy unites physicians and other members of the CIN to maximize efficiency in their practices. An example of a comprehensive physician affinity strategy is combining the available data on a single platform and creating a common way to view and analyze it, depending on the network’s underlying adoption strategies. One of the ways to support this is through bi-directional data integration, meaning that the vendor of the CIN’s platform does not only pull data from the EHR systems but pushes data back into them as well. That vendor’s data will appear in the existing EHR, so the physicians within the CIN do not have to use another system to share insights between members.
Bi-directional integration allows data to move directly into provider workflows and other population health management tools, allowing for more scalable interoperability. The capability supports an airtight physician affinity strategy that meets beneficiary needs and creates a holistic record for them from the beginning to end of their care journey.
Varied Risk Stratification Methods
To accurately stratify risk, it is important to utilize different predictive methods to discern a patient’s likelihood of becoming high-risk or comorbid, going to the emergency room, identifying unnecessary costs, and other insights. The process is simplified further when they are performed within the unified platform. Some of these measurements include hierarchical condition category (HCC) coding, the Johns Hopkins ACG® System, the Elder Risk Assessment (ERA), the Charlson Comorbidity Index, the NYU Algorithm, and Milliman Advanced Risk Adjusters (MARA).
Referral Management Capabilities
Using a built-in referral solution to match and manage patient referrals helps maintain strong CINs. These solutions support closing the loop between patients and specialists; they should enable physicians to create preferred and provider networks and match specialists based on factors like quality outcomes, costs, location, and patient preferences. CINs need to steer patients back to contracted providers if they visit a specialist outside the network; the CIN will have to make up for the loss if a patient continues to visit out-of-network providers. Costs can compound if a patient is high-risk or already considered high-cost and continually returns to these providers.
Unified Care Management Practices
Operations should remain unified throughout, but especially when it comes to care management. CINs are made up of many different providers with different styles of treatment; organized CINs should rely on one means to track compliance to care plans, approach intervention, and close care gaps in populations. The need for unified care management intensifies if they are thinking of contracting for risk. Without access to a patient’s health information to deploy immediate care, providers in a CIN may find themselves at a disadvantage, facing higher utilization costs and potentially poorer outcomes.
The COVID-19 pandemic has heightened the responsibilities of CINs as the need for information, detailed health records, and the assessment of risk factors can determine the outcomes of patients that come in contact with the virus. For more resources on the policy changes and other helpful information on the coronavirus situation, visit our blog and the COVID-19 Resources page.
Maha Salah-Ud-Din is the Director of Advisory Services at Lightbeam.