4 Steps to Position a Clinically Integrated Network for Value-Based Care Success

Clinically integrated networks (CINs) are gaining traction as the collaboration model of choice to enable higher quality health care at lower costs. These partnerships of like-minded independent providers and hospitals with shared performance improvement, quality, value, and efficiency goals can have a profound impact on patient outcomes while decreasing overutilization.

However, a CIN that aims to succeed in a value-based care environment must not only align strategically with stakeholders but also incorporate a technology infrastructure and administrative toolset to support patient-centric workflows and risk-based payment models.

To promote quality of care and cost efficiency, CINs must complete 4 essential steps.

Step 1: Create a Unified Longitudinal Health Care Record

To deliver value-based care, a unified and holistic view of the patient is essential. Digitization and co-relation of health data to create a patient longitudinal health care record (LHR) is necessary. This effort requires 2 major streams of work: a) the creation of a data infrastructure based on ontology, utilizing patient data sets plus external publicly available data sets, and b) proper digitization of unstructured/semistructured data sets.

In a traditional relational database, changing from a single-value to a multi-value property typically requires the entire column for that property to be deleted and a new table created that contains all the new property values. This effort not only takes time but also invalidates the indices of the original table as well as any queries users have written.

Ontological languages for data, on the other hand, are incremental by their very nature. This allows a data model to be enhanced or modified after the fact simply by modifying the concept. There are 18 different ontologies patient data sets can fall into, including Immunity Tests, Disease Registry, Demographics, Claims and Remittance Data, Pharmacy Data, Clinical Data, SDoH Data, and more. All this data needs to have an underlying enterprise master patient index to link the datasets to the right patient and the unique identity enumeration for that patient.

In addition to ontology-based mapping, a unified LHR requires the integration of structured EHR data sets as well as digitized unstructured and semistructured health data. Unstructured and semistructured health data represents most of the clinical data available on patients and includes information such as charts, notes, images, audio and video files, and free form texts or character large objects.

Consolidating and digitizing this unstructured health data with the help of artificial intelligence, machine learning, and natural language processing technologies makes it possible to synthesize data sources of different kinds, address their inconsistencies, help identify errors or misreporting, and seamlessly integrate credible new feeds. Furthermore, it enables proper data analysis and forecasting, which is very much needed to move to a value-based model based on outcomes.

A patient-centric LHR that leverages ontology-based data mapping and digitized unstructured data allows data to be easily shared among CIN stakeholders in a permissioned manner. Plus, it allows physicians to make better decisions by providing a 360-degree view of the patient.

Step 2: Support Complex Hierarchies and Data Sharing

Another building block for administration of value-based care programs is the need to support complex many-to-many hierarchies between entities in the CIN. These relationships become important not only for stakeholder onboarding, data capture, and information sharing, but also to administer payments between the entities.

The transition from a traditional volume-based transaction model to an outcomes-based model that incorporates risk is not easy. Legacy claims and workflow technology systems built for fee-for-service payment structures cannot efficiently accommodate value-based arrangements at scale. One barrier is the inability to onboard and manage a complex multistakeholder care network while accommodating the event-driven and episodic requirements of payment models that are no longer claim-centric. Another is the timeliness of data reporting and the inability to understand contract performance more prospectively, as opposed to after the fact.

An infrastructure that enables many-to-many relationships between CIN stakeholders and the administration of funding pools, including downstream distribution of funds and data exchange to participating partners, is a critical factor to successful value-based execution. A hierarchical approach is a necessity for alignment of medical, social, behavioral, and environmental components in value-based program administration and high-performance networks that confidently deliver on healthy patient outcomes.

Step 3: Provide Broad Access to Care and Unified Care Management

Since CINs are comprised of many different providers with different styles of treatment, establishing broad access to care throughout the network, as well as unified care navigation and management, is vital to ensuring optimal patient flow and experiences.

CINs should offer patients multiple channels to connect with providers, including telehealth options that allow for quick assessment and triage of patients to navigate them to the most appropriate environments for care. An integrated referral solution should also be leveraged to close care loops between primary care physicians and specialists while also enabling the creation of preferred provider networks based on outcome quality, costs, location, and patient demands.

In addition, CIN care management operations should remain unified throughout the network. All stakeholders should adopt 1 means to track care plan compliance, manage intervention, and close care gaps. Each of these efforts will help CINs keep patients in-network and avoid lost revenue that results from patient leakage.

Step 4: Implement Compensation Models That Reward Performance Over Volume

Finally, CINs will be unlikely to succeed in a value-based care environment if their compensation models still reflect the characteristics of traditional fee-for-service care delivery. Provider compensation models and incentives should reward behaviors compatible with value-based contracts and coordinated care.

For example, monetary incentives should be built around measures such as annual wellness visit completion, hierarchical condition category interactions, and short-term and online bookings.

Most CIN stakeholders already have technical infrastructures in place—ones that do not support the hierarchies or ontology-based foundation layers outlined in this commentary. This begs the question: How can a CIN supplement existing technology investment while still gaining the advantage of a robust data/microservices/hierarchy support infrastructure that facilitates successful delivery of value-based care?

Luckily, such an incremental approach is feasible without a rip-and-replace strategy. It requires a platform infrastructure to integrate data layers seamlessly, then extend that data layer either as a data-as-a-service (DaaS) or a platform-as-a-service (PaaS), allowing CIN stakeholders to leverage existing applications served up as microservices.

Support for the hierarchical needs between CIN entities, coupled with an adaptive data and microservices infrastructure, will accelerate the adoption and scaling of value-based care.