Healthcare Technology Featured Article

January 10, 2014

Developing a Clinical Messaging Strategy for Payers: Why and How

The emergence of patient-centered accountable care has created a paradigm shift among payers with respect to clinical messaging. An increasing number of payers now recognize that effective electronic clinical messaging between payers and providers is a business imperative. The pursuit of value through lower costs and increased quality is driving change in care delivery and payment models. Payers, hospitals and providers are increasingly being held accountable for offering greater care efficiency while improving care quality. New incentives have created a need for better collaboration and information exchange among payers, providers and patients in support of the patient-centered accountable care model of care delivery.

The needs for greater collaboration and secure electronic communication are being amplified by new features within the financial landscape, including pay for performance, star ratings, hospital readmission penalties and regulation of payer medical loss ratios. These and other factors are driving payers to enhance performance of their provider network through proactive population health management, improving the coordination and continuity of care, reductions in overuse and waste, and putting systems in place to enhance both patient and provider experience.

Greater access to and use of clinical messaging facilitate these improvements. Current processes do not routinely ensure that a patient’s care team — including hospitals, primary care physicians, specialists, mental health providers, skilled nursing facilities, pharmacists and care coordinators — will receive timely notification if that patient is admitted to an acute care hospital, or seeks care in an emergency department. ADT alerts, a type of clinical messaging, improve coordination of care and reduce the likelihood of preventable readmissions.

Referral management is another area where secure electronic clinical messaging can make a difference. Whenever a referral is made, clinical messaging can be used to transmit patient care summaries so the specialist can be better informed and avoid duplicate testing. Electronic eligibility checking and electronic prior authorization (ePA) can be used to streamline administrative processes, reducing cost and improving the care experience.  Clinical messaging can be used to improve the management of medication use through ePrescribing, medication adherence messaging, fill status alerts and ePA for medications requiring approval from the payer.

Successfully developing and implementing clinical messaging programs is easier said than done. Many complex factors must be taken into consideration and payers are wondering how best to proceed. The answer: a clinical messaging strategy that is tailored to the unique needs and capabilities of each payer’s provider network, markets and infrastructure. The goal is to align plan design, performance measures and payment models. Payers would like to see use of shared care guidelines among all providers. They would also like to proactively identify and engage high-risk populations. Payers and providers would like to:

  • Close gaps in care.
  • Improve coordination of care.
  • More effectively share care planning and decision making.
  • Improve postvisit and postdischarge follow-up.
  • Increase the use and effectiveness of self-management. 

Greater access to and use of clinical messaging services can facilitate improvements in each of these areas.

For payers, there is good news and bad news in gaining access to these services. On the positive side, electronic health record and health information exchange (HIE) software vendors continue to enhance the capabilities of their software and services. Secure clinical messaging provided by SureScripts, Kryptiq, Availity and NaviNet is more available than ever, along with increased use of the Direct secure messaging protocol. Very comprehensive HIE and decision-support software and services are available from Optimum Insight, Sandlot Solutions, Orion, Aetna-Medicity, dbMotion and others.

On the more challenging side of the equation growth in HIEs is slowing, partially due to the end of most federal funding. Regional and state HIEs provide a mixed experience; some have succeeded but others are failing. Increasing challenges and opportunities associated with accountable care organizations will accelerate the sorting out of successful versus unsuccessful HIEs. Payers must navigate this landscape carefully while recognizing that improved clinical messaging is essential to achieving their cost and quality goals.  

An effective clinical messaging strategy begins with answers to a core set of questions that include:

  • What data-driven, pay-for-performance and incentive programs are currently or expected to be in place? How can they be adapted to motivate hospitals and providers to adopt and utilize clinical messaging?
  • What quality programs, measures and reporting systems are in place? How may they be adapted to stimulate use of clinical messaging?
  • What technology infrastructure is in place and how can it be leveraged for clinical messaging?
  • What HIEs are in place, and who are the participants at the state and substate levels?
  • What gaps in resources and capabilities exist and how can they best be addressed?
  • What data sets and analytical capabilities are available?
  • What are the costs, potential risks and benefits associated with a viable clinical messaging strategy?
  • What is the current and projected provider mix?
  • What market and demographic factors must be taken into account?

By answering these and other questions, a strategic framework for clinical messaging can be developed that incorporates tactics and measures along the dimensions of cost, efficiency, quality, outcomes and stakeholder engagement. Value and return on investment can then be quantified.  

Edited by Blaise McNamee
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By TMCnet Special Guest
Ed Daniels and Bill Hein, Practice Lead, Health Information Exchange and Payer/Provider/ACO Executive Lead, Point-of-Care Partners ,

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