The Cayman Islands ACO Roadmap

We are implementing a new care delivery and economic model called “CayHealth” which, at a very high level, seeks to maximize the quality of care delivered while assuring an economically sustainable healthcare system for the Cayman Islands. CayHealth is very similar in nature to the emerging Accountable Care Organizations (ACO) in the United States. We expect HIT vendors involved in the Cayman Islands to offer solutions which clearly and naturally support CayHealth concepts and requirements, as described in the maturity roadmap below. Those of you familiar with the recently released Premier ACO Roadmap will see some similarities, but the two efforts were developed independently, which is a good indication that there is a convergence of professional opinion on the future of healthcare which crosses international borders. Each level of maturity builds upon the functionality of the preceding level.

Level 1: Clinical Efficiency

Data collection regarding patient encounters is optimized for clinician efficiency and outcomes analysis. Narrative text is facilitated through the use of templates, computerized order sets are directly driven from evidence-based medicine, and discrete data collection supports national and international benchmarks for clinical quality at the clinician and organizational level. Clinical productivity is easily measured and reported. All internal orders are electronic. External pharmacy orders are also electronic. A patient-centric web portal disseminates lab and other diagnostic results and clinical reminders. Positive patient identification occurs through card swipes or biometrics and also supports electronic eligibility verification. Claims submission and payment processing (including reimbursement) is completely paperless. The economics of reimbursements remains primarily procedure-based and fee-for-service. Mobile healthcare applications are pervasive for enhancing clinician efficiency, quality and timeliness of care, and patient engagement in their own care. The user interface of the EHR is highly and easily customizable through widgets and gadgets, giving clinicians significant control over configuring the user interface that suits their preferences best.

Level 2: Communication and Economics

The EHR elegantly facilitates closed-loop care-team coordination and communication regarding patient status and pending activity. Reminders for health maintenance are electronically pushed from the EHR to the patient and automatically schedule follow-up appointments and procedures. The referral process is facilitated by that ability to choose, schedule, and communicate with referral physicians electronically. Disease management reports are native to the EHR and push reminders to physicians and patients. Patient management is based upon disease and risk registries that come bundled with the EHR and can be locally customized. Clinical reminders about patients are pushed to the responsible members of the care team, including family members, if desired. Clinical documentation and billing processes are now dominated by capitated, per-patient-per-month reimbursement models. Insurance implications and Total Cost of Care assessments are facilitated by the EHR, enabling point-of-care discussions about projected costs, outcomes and treatment options between patients and physicians. Quality of care reporting is natively supported by the EHR and patients and physicians are financially rewarded by insurance companies and direct contract employers for achieving health-related goals. The EHR and HIT financial applications are designed to support this economic feedback model. Personal health records are widely used by patients and the care team, including health coaches and case management professionals. Patients’ health maintenance plans are based upon computerized health risk assessments. E-prescribing with local pharmacies is full-duplex, allowing for medication reconciliation. Systemic monitoring and notification of abnormal test results ensure closed-loop communication with the care team and patient.

Level 3: Pervasive Analytics & Health Monitoring

Quality of care dashboards are fully integrated with the EHR which allow clinicians to move seamlessly between population-based monitoring and patient-specific care delivery. Population-based and patient-specific health status reporting from remote monitoring devices, videoconferencing and mobile self-reported outcomes support the health management of many patients, regardless of location, by relatively few nurses and physicians operating from a “Health Command Center”. The EHR’s analytics engine natively supports reports for proactive profiling and management of high-cost, high-risk, high-utilization patients. The EHR is beginning to accommodate Personalized Medicine. Genetic and familial tendencies are easily recorded and displayed for reference in the EHR.

Level 4: Social Wisdom

Content and analytic feedback is integrated into the care delivery process of the EHR which allows clinicians to answer:

• Which of my colleagues has seen patients like mine?
• How were patients like mine most commonly treated?
• What were the outcomes of treating patients like mine with this clinical protocol?
• How did patients like mine rate their care delivery process and outcome?

Patients are engaged in this social wisdom dialogue through their Personal Health Record and mobile applications are used to fully-engage patients in healthy lifestyles. EHR functionality exists to automatically update and notify clinicians to recommended changes in evidence-based protocols based upon the real-time feedback of diagnostic tests, devices, and patients’ self-reported outcomes.

Level 5: Personalized Medicine & Wellness

Personalized Medicine is fully integrated into the EHR so that generic evidence-based order sets and lifetime health maintenance plans are now tailored dynamically towards the genetic and familial tendencies of the patient. Remote monitoring and telemedicine/e-visits constitute at least 50% of the encounter types. EHRs facilitate the data collection and analysis of patient treatment and protocols so that hospital financial systems are capable of actuarial and risk forecasting to enable a growing trend towards self-pay, high deductible health plans, and employer direct contracting for healthcare coverage, reducing the dependence on third-party insurance.