A Model for Advanced Care Management and Implications for Information Management

• Introduction
• Integrated Care: The Context for the Information Revolution
• The Information Revolution: Trends in HCO Information Technology
  • Supporting Providers
  • Managed Care Operations
  • Meeting Member Needs
• Health Sector IS Developments in New Zealand
  • Greater Collaboration
• Conclusion
• References

Introduction

This paper considers the implications for information management within an integrated care environment in three stages. It begins by describing integrated delivery systems (IDSs) and the demands that they create for information management. While integrated care has organisational challenges for the care of patients across organisations, in many respects the challenges for developing effective information management across organisations are greater, both here and overseas.

Secondly, it provides a description of some recent technology trends for both IDS and financing/insurance organisations including managed care organisations (MCOs).

The paper finishes by outlining some recent information system (IS) developments in the New Zealand health sector, particularly those supported over the last year by the Ministry of Health’s Health Information Initiatives Programme.

It is important to emphasise that there is little point expending energy on developing an organisation’s information management structure unless the link between basic business strategy and the organisational processes needed to enact that strategy have been identified. The current change occurring in health care organisations (HCOs), when combined with change at the sector level, means that there is even greater turbulence when it comes to understanding the opportunities (and costs) of new technology and information management tools.

Integrated Care: The Context for the Information Revolution

Current health sector dynamics motivate many organisations to assemble historically fragmented components of the health care system – hospitals, GPs, emerging health plans, post-acute services, etc – into integrated delivery systems. Integration can be defined as “the optimisation of interactions among components of a system to provide health services of high value to those served”  ¹  .

The primary objective of integrated care is to ensure each client receives the appropriate level of care (including preventive services) at the appropriate cost, and with appropriate outcomes.

A recent Hospital & Health Services Administration article on clinical integration notes that "simply forming an IDS, even one with all the needed components, while necessary for … integration, is not sufficient to actually achieve it."   ²   In other words, the whole should be greater than the sum of its parts. In reality, many IDSs have been content with establishing linkages amongst providers but have failed to establish mechanisms for optimising the delivery of care across providers. This section highlights the principles and elements necessary for fully integrating health delivery within an organisation, in order to understand how information technology can support the endeavour.

Principles
Progress towards integration can be assessed according to four criteria   ³  : (1) co-ordination of clinical activities and services among operating units; (2) avoidance of unnecessary duplication of clinical facilities and services; (3) appropriate sharing of clinical services among operating units; and (4) integration of clinical services and facilities to achieve cost-effective patient care. Since the ability to manage outcomes and resources is a common goal for IDSs, medical management invariably appears as one of the critical success factors for integrated systems.

Thus, key to integrated care are the programme components, competencies, processes, and infrastructure necessary to manage and deploy the appropriate clinical resources within the system to achieve this objective.

Integrated delivery systems go beyond traditional utilisation or case management programmes by evaluating care in all settings against a more comprehensive set of criteria (eg, quality, cost, patient satisfaction and health promotion) and within more aggressive timeframes (eg, prospective as opposed to retrospective review).

Elements
Programme elements in the delivery of health care services include:

• Health Risk Assessment
• Primary Prevention
• Demand Management
• Triage
• Outcomes Reporting
• Provider Profiling
• Utilisation Management
  • Protocols
  • Resource Use Targets
  • Referral Guidelines
  • Practice Guidelines
  • Pathways.

A key task in integrated care is to transform the programme from a series of independent elements to a truly integrated system capable of managing care and resources. As such, integrated care reflects the full continuum of care.

Information technology and systems and network management are key approaches in achieving this goal.

Other supporting elements for coordination of activities across various elements of the broader programme include: conventional case management, which attempts to streamline activities associated with a particular episode of care and; disease management, which encompasses a broader spectrum of health care settings and focusses on integrating services for a particular disease state, such as asthma, congestive heart failure or diabetes.

Key to this integration are: multidisciplinary teams that drive the system; enhanced communication and documentation throughout the system; services redesigned to allow departments and operating units to share resources, and; well co-ordinated patient care and service across the different settings and departments.

The Information Revolution: Trends in HCO Information Technology

In integrated care delivery, information management and technology have a much greater role to play in enabling clinical staff to better manage patients. Real-time clinical decision-support tools, clinical “rules” that are driven from clinical information combined with prescribing options for example, are increasingly in demand.

HCO success increasingly depends on effective collection and management of information. As the market continues to consolidate, financial risk shifts to providers, pressure grows because health plan accountability and information needs are becoming more complex. For example, larger quantities of data will be needed for supporting effective decisions. This same data must be accessed by a number of different people, possibly for different purposes, at the same time. Furthermore, the lead time for fulfilling data needs must decrease while the real-time availability of information must increase.

Appropriate use of information technology is becoming a competitive necessity rather than merely a competitive advantage. It is anticipated that technology will help to improve the operations of the HCO as well as to improve the linkages between MCOs and other stakeholders in the health care system.

There are several examples of emerging technologies from the MCO and IDS perspective as follow.

Supporting Providers
A number of technologies support providers and offer strategic advantages for both IDS and the MCOs. For example, computer-based patient records (CPRs). Although of benefit primarily to the clinician in that CPRs eliminate paper and expedite access to information, CPRs are also of benefit to health plans for their ability to help in management of the care delivery process. A CPR can provide the ability to assess clinical outcomes and support the development of clinical pathways to enable more consistent care across providers. One New Zealand example at the forefront internationally is Auckland Healthcare’s clinical data repository using cutting edge Microsoft object-oriented COM technology.

Like CPRs, Health Information Networks (HINs) can also provide a strategic advantage for the health plan. A HIN is an innovative combination of services, products, and technologies that enables organisations to exchange clinical, financial, and administrative information electronically with other designated organisations. Through the electronic sharing of information, HINs support the health care financing and delivery process. New Zealand examples of intra-regional co-operation and planning can be found with MidCentral Health’s Regional Clinical Information Network activity as well as other more localised initiatives.

Other functions where automation supports more effective processes include: electronic eligibility and benefits inquiry, provider directories, electronic referrals and authorisations, electronic claims processing and reimbursement, enterprise scheduling and clinical guidelines. While New Zealand has had electronic data interchange technology for several years, there has been little automation of decision-making processes.

The Internet is being used in several different ways by MCOs to support and work with providers, for example in strategic partnering and in data transmission. In “strategic partnering” MCOs have used the Internet to establish relationships and to set up strategic partnerships with providers. The Group Health Co-operative of Puget Sound provides its physicians with on-line access to clinical information. Blue Cross Blue Shield of Massachusetts sends screening reminders via automatic electronic messages to physicians to remind them that a patient is due for a mammogram, Pap smear, or cholesterol screening. Web-browser clinical decision support tool eCareWeb in Auckland is a static example of this opportunity.

As for data transmission, technologies such as the Internet and World Wide Web are providing an excellent opportunity for the critical exchange of information between providers and MCOs. With the development of electronic commerce this trend is set to grow even more rapidly than before, particularly with the expected growth in health purchasers under workers compensation deregulation.

Electronic ID cards are another tool for creating strategic partnerships with physicians. Blue Cross Blue Shield of Massachusetts has established a voluntary and confidential electronic medical information tracking system. With the swipe of an ID card, doctors have instant access to medical conditions, allergies and prescription drug history.

Operational Efficiencies in Managed Care Organisations
Technology can help MCOs to increase operational efficiencies. There are a variety of critical technologies which include those outlined below.

Data warehousing
Data warehousing facilitates easier access to information. A data warehouse may provide a source for clinical data, financial decision support, marketing, provider credentialing, claims administration, and research. Data warehousing requires creating a separate database for integrating data from disparate systems. Data warehousing is a very real opportunity for many IDSs who maintain separate business systems, but who need to call on shared data for analysis purposes.

Core transactional processing systems
Core transactional processing systems reflect the day-to-day activities of business and capture the front-line data which feed decision support systems.

Document imaging/management
Document imaging involves the online storage, retrieval, and management of electronic images of documents. This technology is especially useful for claims processing activities. Imaging puts information in users’ hands faster and with more security and control than paper documents, leading to more productive workers and better customer service.

Some organisations are also beginning to use document management technology. This technology, based on a client/server topology, facilitates access to stored documents that have been scanned or entered manually into the system. Examples include case-mix feeder systems, parental dental authorisations and referral letters.

Triage systems
Triage systems are generally used as a type of member service within an MCO. A software programme guides a service representative through a list of questions and responses based on the patient’s supplied information. This software helps in determining the urgency of care as well as the directing of care.

Networking technology
Networking technology (including intranets) can be used to create internal operational efficiencies. For example, Harvard Pilgrim Health Care established a centralised network that links all of its clinical, administrative, insurance, sales and marketing systems to provide widespread access to information and reduce duplication of data entry.

Integrated voice response and workflow management systems
MCOs are beginning to automate many customer-oriented processes and functions. Integrated voice response and workflow management systems can increase operational efficiencies, improve responsiveness to customer enquiries and generate useful data on customer interest and process performance.

Meeting Member Needs
Technology can also help MCOs manage the demand for health care services by its member population.

Home monitoring
Home monitoring enables a member’s health to be tracked by the health care system while the patient remains at home. Quantum Health Resources in Indianapolis supports home-based treatment of haemophilia patients. With software, patients keep logs of their daily infusion treatments and send the records via modem to Quantum for review.

Internet/World Wide Web
The Internet and WWW can serve as a useful medium for transmitting wellness information, conducting transactions with members, and implementing sales and marketing programs.

Demand management
Access to wellness and educational information via the Internet (interactive multi-media, topic-specific chat rooms, bulletin boards, user-specific news/research requests) is easier than ever before. The Internet can also be used for member/clinician education, treatment protocols, disease management information, and preventive morbidity and mortality information.

Member transactions
Prudential HealthCare already provides Internet-based transaction services which allow members to change their primary care provider on-line, look up doctors/dentists and check their background, obtain directions, assess the status of a claim, download claim forms, request ID cards, review benefits summaries and send questions directly to member services. Kaiser Permanente (Northwest) allows members to refill prescriptions online as well as make non-urgent medical and dental appointments.

Sales and marketing
The Internet also provides an excellent opportunity for MCOs to target prospective members and generate new business. Columbia/HCA uses its web site as an important tool in its branding strategy and has taken an important step in identifying tangible benefits from its web investment. Visitors to the site are asked to register by entering some basic demographic information. As web access expands, the company expects to more clearly identify its target audience by market.

Multimedia
Multimedia technologies provide an excellent tool for interactive member-oriented activities such as patient kiosks and education. Examples of multimedia technology include CD-ROM and video-conferencing.

Managing distribution channels
Technology will help an HCO to work more efficiently with their existing distribution channels as well as provide them with new, more direct channels. For example, many insurance and financial service organisations are beginning to use Internet technology. They can refer customers to agents and brokers through the Internet. Others plan to use this technology to completely bypass agents, thereby lowering their cost of sales and making their products more competitive. HCOs have significant opportunities in support processes such as supply chain, as well as for inter-HCO patient processes.

The development of Internet technology extends beyond current “passive” deposits of information on the Internet. Leveraging information and knowledge into work practices, combining or eliminating functions, is a real opportunity.

Enhanced Effectiveness
In addition to enhancing operational efficiency, technology plays an important role in enhanced effectiveness of care delivery, improving quality of care and health gain, for example through decision support systems.

Health Sector IS Developments in New Zealand

Health sector information management in New Zealand has traditionally been fragmented.  ⁴   Recent years of “competitive” cultures and fragmented purchasing strategies have exacerbated this. While fortunate, relative to other countries, in having a national health index and a good number of providers utilising a common case-mix system, the health sector in New Zealand has not truly leveraged these or other opportunities. A collaborative approach to IS infrastructure between providers remains largely absent.

Government agency involvement in information management has continued to provide some investment leadership, such as the Health Funding Authority (HFA) funding primary care infrastructure and file transfer mechanisms. However, these have in large part fallen short of what the sector would have preferred.

The Ministry of Health, through the 1997 Health Information Initiatives Programme, provided leadership by facilitating a range of benefits for providers. The following sections illustrate some themes that emerged from the programme, associated with greater collaboration, the role of a central organising body and the role of project management. These themes highlight typical benefits that arise from and issues that emerge in the development of integrated care. The issues point to some of the technology investments being made throughout the sector in response to these issues.

Note that the benefits outlined below refer, in the first instance, to organisations that participated in the programme.

Greater Collaboration
During the programme, collaboration became more apparent across several dimensions. This could be seen, for example, in the areas of evidence-based medicine and the provision of services to rural populations, in the attempts to improve disease management at a national level, in the need to think from a national perspective, and in the developments of the relationship between primary and secondary providers.

Evidence-based medicine
Sharing of clinical decision-support information has occurred amongst providers and also the New Zealand Guidelines Group.

Provision of services to rural populations
Providers in different rural centres have collaborated remotely in a rigorous scientific approach to determining effectiveness of new technologies.

Improving disease management nationally
Experienced disease management researchers have collaborated to share current knowledge for the purposes of achieving mutual aims embodied in the project.

Beyond regions – thinking from a national perspective
The programme served to remind project sponsors of the need to consider the wider health sector while addressing regional needs. By establishing an expectation during the chartering phase for sharing both solutions and experiences, project sponsors were more inclined to consider issues of transferability, scalability, documentation and record keeping, etc.

Developments in the relationship between primary and secondary providers
Although this was probably the most expected dimension of collaboration, it has been the one fraught with the most difficulty. Issues have arisen surrounding GP governance, channels of communication between providers, participation over consultation, and creation over prescription.

Roles of a Central Organising Body and Health Care Providers
Developing greater collaboration has meant that both the role of the symbolic Government “Centre” and the provider’s behaviour has been questioned. This happened, for example, in dealing with issues of sharing knowledge and expertise, of incentives for improving patient care and in defining the role of the Centre.

Sharing “know-how” – the Greater Good over Competitive Advantage
Recognising that “know-how” is not necessarily competitive information has enabled win–win opportunities to be developed, while providing more commitment to collective, responsible, experimentation.

Dealing with provider incentives for improving patient care
Discussions based around the costs and benefits of implementing “patient-focussed” services have encouraged the addressing of issues, for instance, the implications of potential cost-shifting between providers.

The Centre neither prescribes nor has all the answers
HCOs have progressed over the course of the programme from resentment (for requiring collaboration), to reluctance (based on the Centre not prescribing solutions) to collaboration (“let’s work together”). By not prescribing solutions, the “Centre” has encouraged HCOs to collaborate in developing more pragmatic solutions to their and their patient’s needs.

The Project Management Role
Issues related to project management which were identified included the need for templates and materials, and the need to formalise the project management discipline and actively manage communications.

Identifying templates and materials to develop skills
Early concern surrounded the apparent lack of rigorous project management skills in the requests for funding. A “Guide for Project Managers” was provided as a resource to participants to support and encourage them throughout the chartering and monitoring stages. This has provided participants with a consistent methodology, terminology and documentation templates.

Project management discipline
Formalising project management has produced benefits such as developing “workable” scope, clarity in responsibility, more sound project plans, and more effective issues management.

Communicating is time and resource intensive
Project managers have commented that the active management of communications has been rewarding, despite requiring significant effort.

A Role for Information Technology
The role for information technology solutions became apparent throughout the programme, particularly in the areas of the networking of interested parties committed to improving the sector, understanding the value technology can provide, and improving the approach to technology investments.

Networking of interested parties committed to improving the sector
A variety of skilled participants from around the country have had the opportunity to network. Feedback suggests that as a result they are able now to push developments forward faster and with greater confidence than before. By sharing frustrations, experiences and ideas providers obtained “comfort” that others are often facing similar issues.

Understanding value that technology can enable
Linking the benefits promised by technology implementation to actual improvements in patient care and/or more efficient processes was a challenge for many projects. The development of “value propositions” within a project’s charter encouraged more rigour to be applied to technology-enabled people and process change.

Improved approach to technology investments
There now appears to be greater awareness of how to approach technology projects than before. Technology is only part of a solution. Process and people issues require greater effort in a successful technology project than does the actual technology solution itself.

Conclusion

Information management is an exciting area of opportunity for all HCOs. Key reasons include the shifting nature and role of HCOs and emerging models of financing/managed care organisations.

As integrated care develops, the need for rapid, sophisticated information grows. Information management solutions are required to support the core elements of a continuum of care model. As MCOs develop greater risk and capitation models the importance of non-financial systems, eg, those that support advanced care management, will be critical. Precisely for this reason, it is imperative that HCOs effectively consider both their strategy and process configuration and then plan how investment in information management can enhance them.

The health sector in New Zealand, although still comparatively fragmented, contains many examples of innovation in service delivery and technology. It is important that HCOs continue to develop increasingly collaborative approaches to improving patient care while improving resource effectiveness. Information management provides a variety of solutions to the continuous challenge of improving care management in an IDS.

References

Ernst & Young “Information Technology for Integrated Health Systems,” 1996
Various Ernst and Young Global Knowledge Repositories and Gartner Group research notes

Notes