Leveraging Standards for ACO Development

One of the things I didn't get to do at HIMSS was connect up with someone who wanted a brain dump from me on leveraging healthcare standards to support Accountable Care Organizations.  One of my recent tweeps asked if EHR was required to support ACOs, and another responded that EHR is not, but that an HIE is.  To add to the alphabet soup, I'd like to throw in CDS.

What I'm hearing about most often from Accountable Care Organizations is that they are focused on cases where they can quickly realize savings.  The low hanging fruit seems to be in the area of chronic disease management, care planning and follow-up.

The top chronic diseases appear to be Diabetes [all seem to agree this is a top priority], Chronic Obstructive Pulmonary Disease (COPD), Congenstive Heart Failure (CHF) [these next two are very common], Coronary Arterty Disease (CAD), and Hypertension.

Other areas of attention are on care-planning and follow-up for post-surgical and post-ED visits.

From a standards perspective, the key areas of focus is on sharing data from various settings where the ACO has access to it.  The standard that most are already adopting is the HITSP C32/HL7 Continuity of Care Docuement as it is already contained within the Meaningful Use Regulation.  Another area of attention is on accessing laboratory results.

From a vocabulary perspective:
While many are still using ICD-9-CM codes for diagnoses, some are pushing for SNOMED CT codes.  For medications, the push it towards RxNORM, and for labs to LOINC.

So far, motherhood and apple-pie, and consistent with national directions.

Where their seems to be some struggle is on data elements needed for managing care for each of these cases.  I expect there there are still quite a number of spreadsheets being tossed around.

The next step for standardization in this area would be to apply codes to the various guidelines for treating these diseases.  The hard part is deciding on which guidelines to apply for care.  The easy part is selecting the codes for the important components.  Let's take an example of what I mean, by looking at the International Diabetes Federation's Global Guideline for Type 2 Diabetes.  I picked this guideline arbitrarily, you could use any other guideline for this effort.

Having chosen the guideline, let's take a couple of its recommendations and apply codes to them:
Guideline SD2 (see Page 9 of the PDF above) recommends a fasting oral glucose tollerance test for screening.  So, now we need to code the tests.  Out comes RELMA and we find that the most common test in LOINC^® is: 1504-0 Glucose^1H post 50 g glucose PO mg/dL.  There are some 92 other result codes that we could also look for, but I won't bother listing them.

Guideline SD4 (same page) references the WHO criteria for diagnosis of Diabetes (peeling the onion as it were).  So, now I dig out my CliniClue Browser and look up the code for Diabetes Melitus (73211009 in SNOMED CT^®).  Since I'm interested at this point in all subtypes of Diabetes underneath that code, I'll deal with that as an Intentional value set.

If we wanted to address other means of screening (e.g., Urine dipstick testing), I could look up the codes for those in RELMA as well.

I'll skip the Care Delivery section and move on to the Education section since Care Delivery references content in the other sections.

Guideline ED1 talks about Diabetes Type 2, so again I find the right SNOMED CT code (44054006).

Guideline LS2 talks about a type of care provider: dieticians.  I can dig up SNOMED codes for that, or use the Healthcare Provider Taxonomy codes (a Registered Dietician is 133V00000X in that coding system).

Guideline TT1 talks about HbA1c levels, so I need LOINC codes for that.  I find two codes in LOINC using RELMA (both of which are common):

• 17856-6 Hemoglobin A1c/Hemoglobin.total % Hgb
• 4548-4 Hemoglobin A1c/Hemoglobin.total % Hgb

Diabetes can cause retinopathy, so there are guidelines around eye screening.

Guideline ES1 talks about Eye Examinations, so I can find CPT codes for that (but not display them...)

It also discusses retinopathy, so I can find SNOMED CT codes for that (399625000) and explicitely for Diabetic Retinopathy (4855003).

 

And so on and so forth until I've got codes for the entire guideline.  Picking the guideline, is, as I said, the hard part.  Coding the stuff is Clinical Informatics drudgery, and can be quickly done (I did a good bit of the IDF guide in about 6 hours).  Some of these codes will be for conditions, others for providers, encounter types, lab results and orders, vital signs, services, medications, et cetera.

 

If I'm smart, for each of these things I've got a code for, I should also have a link back to at least one (if not all) requirements for that thing in the guideline.  This can be used later!

 

The list of coded stuff tells me what I want to see in lab reports, CDA documents, and more.  Having that list makes the job much easier, because now I can make sure that information is captured in the EHR, coded in a CDA document, or imported from laboratory reports (and mapped to LOINC where needed).

 

All those linked references I talked about earlier can also be used in Infobuttons in the EHR, or in patient educational content.

 

IHE developed the Care Management (CM) (pdf) profile to support chronic disease management.  Uptake has been slow, but I'm starting to get feedback on it, and at least one organization has implemented it that I know about.  It's designed around exactly this sort of process, and the beauty of that profile, if it were implemented fully, is the automatic generation of interfaces (no more interface engineering -- imagine taking that cost out of healthcare).

 

The next big challenge for ACOs is applying clinical decision support to this information.  The guidelines supply the rules that should be invoked on the data that we've coded, and those can be written in whatever form (programming language, rules engine, et cetera) needed.  Thomson Reuters is working on an AHRQ grant to develop electronic Recommendations.  This is essentially the step before coding a guideline into Clinical decision support logic.  A necessary step prior to describing the logic is what I just described, coding the guideline.

 

Both the CM profile and the IHE Request for Clinical Guidance (RCG) (pdf) profile support mechanisms to integrate clinical decision support as a service.  The RCG profile includes an appendix to show how to map back and forth from a CDA document to a Care provision message to support the integration of CDS as a service.    The Clinical Decision Support Collaborative is currently investigating how to integrate CDS services with ERHs, and these profiles provide some support and a standards based interface that group could take advantage of.

 

CDS is the next big area where standardized interfaces are needed.  IHE was just a bit early in its development of profiles on CDS, as the current market is focused on Meaningful Use Stage 1.  But stage 2 and stage 3 are coming, and CDS will play a key role in those stages.

I'd love to see some national efforts around the selection of and coding of guidelines for chronic conditions that could be widely shared.  I think that effort would give ACOs a huge head start.  Most often, it's not the codes that change in the decision logic, but the various measure parameters (should HbA1c be managed to 6 or 7%), should medication X be applied at this point or that.  Coding national guidelines in this way would let ACOs get a head start, and if they wanted to adjust the decision logic because they have a better idea of how to manage the condition, more power to them.  At least they could skip the step of finding the codes.  It pains me to understand how much clinical informatics expertise we are wasting doing the same work repeatedly (in some cases, reinventing guidelines that others have already well established).

Oh, and this would be a process that would have quality measurement built in.