Once an accountable care organization (ACO) or other collaborative care entity has laid the foundation for a robust health data exchange by ensuring the electronic capture of complete clinical and financial information at the individual provider level, the next step is to build the core of the structure – the longitudinal patient record.

Even if a physician or clinic is capturing patient health information in an electronic health record (EHR), the information is only valuable to a collaborative care organization if it can be aggregated with patient data from other sources and harmonized to produce a single, longitudinal record that presents a complete picture of a patient’s medical history. This record that includes symptoms, tests, diagnoses and treatments enables providers throughout the care continuum to assess the patient accurately to provide faster and more specific treatment plans.

The most logical starting point for any longitudinal record is the capture of lab and imaging orders and results. Because 70 percent of clinical decisions involve lab and imaging data, it is critical to ensure the inclusion of this information to provide a good beginning to a comprehensive longitudinal record.

[Part 1: Physician practice level data is critical when building an ACO.]

The next step is to incorporate all other clinical information from EHRs, including notes, symptoms, diagnoses, allergies and medications. Inclusion of this information provides the 360-degree patient view needed by providers throughout the care continuum.

The final component of the longitudinal record is financial or claim information. Claims are an important source of information to understand what services have been provided to the patient. This includes data beyond what would be in the EHR, such as outpatient therapy, out of town emergency room visits, etc. While a physician does not use this business data to necessarily support clinical decisions, it is an essential component of information for the ACO at the analytical stage of the data exchange.

Aggregation challenges
Aggregating patient information into one record is a particular challenge to a Medicare ACO, or any collaborative care organization with older patients, due to multiple chronic conditions that require care by several providers at different locations. Although all EHRs are required to provide a Continuity of Care Document, not all EHRs are open and not all formats are easily aggregated.

An additional challenge to building a longitudinal health record for a patient is matching unique records across multiple sites such as physician offices, hospitals, ambulatory care centers and home health — each with its own method to identify records.

Not all providers are consistent with their identification of patients, which increases record integration difficulty. For example, a physician office may identify a long-time patient by the middle name used daily as opposed to the legal first name, or an outpatient practice data clerk may invert numerals in a social security number. If these errors are not caught at the initial point of service, the record is either not accessible to providers or is erroneously combined with another patient’s record. Incomplete records related to allergies or current medications can be dangerous if a patient’s physician is not aware of potential reactions or interactions with new medications.

Without a robust enterprise master patient index (MPI) and a clearly defined minimum set of data required for identification of patients by all ACO providers, information compiled as a patient’s longitudinal record will be incomplete or inaccurate. This may result in clinical decisions that do not take into account the patient’s entire medical history or in ordering previously performed tests that are not reflected in the record – increasing costs of care and inconveniencing the patient.

The final challenge is ensuring access to patient information across the continuum of care providers. This requires harmonization of all patient data into standard code sets that can be easily accessed by all providers. Constraints on financial and staffing resources within the ACO make this a difficult challenge to overcome as the organization faces ongoing growth along with changing quality and financial reporting requirements.

Solutions to development of longitudinal record challenges include:

• Provide an open, standards-based platform that can integrate disparate systems, aggregate information and harmonize data to enable access by all providers;
• Develop a clearly-defined minimum set of data for identification of patients and educate all providers to the importance of the information;
• Rely on an enterprise master patient index to ensure accurate consolidation of individual records into a longitudinal record;
• Define the standard terminologies that will be used for aggregated data and create appropriate mappings between different terminologies;
• Implement record updates in the “space” between all providers to minimize workflow interruptions.

Building the core of a collaborative care health data exchange with longitudinal records comprised of robust individual provider records lays the groundwork for the top level of the data exchange and the application of analytics. In addition to providing support for clinical decisions, longitudinal records included in the ACO’s central data repository enable the organization to monitor compliance with treatment guidelines, meet reporting requirements and identify best practices to improve care.

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