Care Coordination Networks: HIE Gets Genuinely Useful

As some readers may know I have been a bit concerned about the business cases and some of the justifications for some of the health information exchange (HIE) projects which are in development or deployed.  There are a number of HIEs which do seem to have well-defined missions and which create value recognized by a critical mass of participants, some quite well-established (to the extent anything is in this area), and these are success stories. Others, however, may not survive the lifetime of the grants used to create them, and seem to be groping for a mission – or hoping others will figure one out and start using the HIE for it.

I truly do hate to see well-intentioned, well-considered, public-good IT projects wind up orphaned, fading and ultimately forgotten. I think we’ve developed and then forgotten a lot of intellectual capital in healthcare IT over the years; certainly I keep encountering issues which have been solved years ago in projects which nobody seems to remember. So, I’m hoping that care coordination networks (CCN) will be a factor which help turn struggling HIEs into useful, sustained utilities.

Certainly it seems to me like the stars – or financial incentives – are coming into alignment for CCNs. Something’s certainly happened to motivate a number of organizations I know to start organizing them, including IT vendors and services providers. Probably part of it is the relatively new acceptance of the cloud as a health care platform, which does allow services to be implemented with lower investment costs. Part of it is no doubt also the promotion of accountable care organizations (ACO) as a solution to control rising health care costs, and include care coordination as a key element.

So what do I mean by  a CCN? Well, let’s start with this definition of care coordination, cited by AHRQ:

“Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.

I’ve added he emphasis on “exchange of information,” and would point out that not only is it “often” managed by the exchange of information, but that it isn’t logically, much less practically, possible to coordinate care without exchanging information. (How could that happen?) So what I consider a “care coordination network” is precisely the set of arrangements a specific group of CCN participants use to exchange the information needed to, well, coordinate care.

A CCN is therefore set up by a set of organizations which have a common continuing interest in providing, paying for or otherwise supporting care for a common population. (Note how this is different from one of the more common justifications for HIE, the anecdote in which the presenter with a broken leg had to hand-carry his X-rays to his PCP, or some such.) Members of the common population generally have a related set of complex types of health issues:  Age-related complex conditions, alcoholism/substance abuse, etc. A CCN might therefore be part of an ACO infrastructure, but I think it can also be its own niche – as long as the financial incentives line up.

Either way, complex conditions require specialties and specialized facilities which are rarely found in an integrated organization – and probably aren’t available at all for patients in a community residential setting – CCN participants need properly adapted HIE agreements which enable care coordination information exchange. Such agreements probably need to be “tighter” than some of the documentation used for some utility model and other relatively “open” HIEs, especially if there are financial incentives or penalties at stake. And of course much of the information to be exchanged is PHI, so HIPAA is implicated.

CCN agreements and policies therefore do need to be developed with careful consideration of the ways the CCN is intended to be used. While most of the purposes for which CCN information is exchanged will be related to treatment, payment or health care operations in some way, and so won’t have to be supported by patient authorization, some probably will not. CCNs should probably also support various kinds of regulatory reporting and related analysis, and while much of this  may also be possible without authorization, again some may not. And of course there are all the issues related to the CCN HIE operator’s status, as a Business Associate or conduit but in any case as a crucial keystone which needs to be managed and maintained.

One of the more interesting developments I’m seeing is the creation of rules engines and other decision support tools of value in care coordination. Knowledge management for complex conditions is a major sleeper issue in health care liability which will inevitably become a significant potential malpractice issue sooner or later – I’ve got an article in the works on changing medical standards of care in an age of EHRs, HIE, decision-support and web services – and this kind of tool can be of great value if it is properly designed and really works. Having said that, one of the better ways to design CCN tools is by analysis of CCN transactions and patterns, which probably entails use or disclosure of PHI – which perhaps isn’t part of treatment, payment or health care operations, under most (though maybe not all) conditions.

So to sum up: I hope the CCN trend I’m seeing portends a real advance in HIE usage, for genuinely valuable uses. But as with so much – everything? – in health IT, it needs to be approached with careful analysis and good documentation. After all, the road to security breaches and HIPAA civil monetary penalties is paved with good intentions . . .

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