UnitedHealthcare is beginning to experience reduced hospital and emergency room use as a result of payers and providers sharing patient data through health information exchange in its eight patient-centered medical home pilots around the country.

What is emerging is that the exchange of clinical information for medical management is getting comprehensive enough at the point of care to be able to evaluate the cost effectiveness of the service, according to Sam Ho, MD, executive vice president and chief medical officer, UnitedHealthcare. 

With that data, “medical necessity determinations can be made closer to real time and obviate the need for unnecessary diagnostic settings and unnecessary treatment referrals,” he said in a recent online presentation sponsored by the eHealth Initiative, a non-profit organization that promotes health IT.

Health information exchange (HIE) can establish common ground for payers and providers based on increasing access to patient data at the point of care. Payers and providers can share that information to simplify administrative activities while also improving quality and lowering operating costs, he said.

The emphasis on HIE has been to improve care coordination and care management, but it can also decrease discretionary or unnecessary costs as well, such as laboratory and emergency room use, he said.

“As we put this together, in terms of administrative simplification and lower operating costs along with improved quality outcomes, you begin to see a virtual integration if not vertical integration of a delivery system,” Ho said.

The benefit of care coordination, particularly where a patient had been admitted to the hospital or visited the emergency room, comes from assuring follow-up care to prevent re-admissions. Some of the medical home pilots have experienced reduced emergency room visits and hospital re-admissions because an episode triggers a primary care manager to intervene.

“Just by doing appropriate mining and scrubbing of the plan data and sharing that data with the physician or the ER or inpatient service, it can develop and identify the opportunities for better care coordination,” he said.

Over the long term, health information exchange that enables real-time notification of clinical information to payers and physicians about any use of ER or inpatient services will be critical.

"That is where the most discretionary utilization occurs, and that’s where the most impact can be achieved in terms of developing more affordable services and healthcare,” Ho said.

By moving pieces of information back and forth across a communications platform, whether through a comprehensive HIE or the simpler Direct Project secure messaging protocols, components of patient and population health data for clinical and administrative purposes can interact, said John Haughton, MD, chief medical information officer of Covisint, a provider of exchange services.

For example, under Vermont’s Blueprint for Health initiative, eight primary care practices, in conjunction with other community providers, over one year increased from 40 to 57 percent the patients with an A1c blood sugar reading of less than 7 percent, a recommended level. The effect has been a significant decrease in the rate of hospital inpatient utilizations and emergency room visits by about 20 percent after one year, he said.

The improvement came from getting the patient care summary in front of the doctor. “This could be just getting a computer-generated piece of paper there.

The Vermont program has assembled a community health team that includes a nurse coordinator, social worker and access to dietitians that are deployed in different locales around providers as a shared resource across various entities to help manage patients.

The community health team is incorporated within a health IT framework, which has population management functions, individual patient lists and individual plans of care available. An evaluation framework also pulls in the financial information as well as the clinical information.