By Dr. Charles Saunders, Integra Connect
Can one of the technologies most associated with the fee-for-service era – the EHR – reinvent itself for the very different requirements of value-based care? We regularly convene leaders from specialty practices nationwide to discuss their value-based care progress and recently posed this question to an audience representing more than 530 oncologists. More than two-thirds of respondents either said that their EHR was not ready, or they did not know whether it was ready, to accommodate “alternative payment models, bundles, or other innovative payment methodologies.”
The physicians’ response is not surprising when one considers that EHRs were built to automate a fee-for-service world. These applications specialize in documenting patient encounters in office settings and converting those interactions into billing codes. As a result, practices are finding that they often fall short in supporting key requirements of the Merit-based Incentive Payment System and/or alternative payment models. Practices report key challenges including the following:
- Inability to capture all required data elements in structured formats. Value-based care requires practices to report out on quality measures based on EHR inputs. Because discrete data fields in legacy EHRs are limited, the necessary data elements typically reside in an unstructured form, if they are consistently captured at all. For example, oncology practices participating in the Oncology Care Model need to document items that were once typically buried in encounter notes, or even omitted altogether, such as tumor staging and comorbidities.
- Poor interoperability. Practices are now called upon to have a more holistic view of their patients’ well-being under value-based care models, but EHRs (and their vendors) tend to resist enabling the data access and integration needed to assemble it. To address this gap, practices needing to integrate with other EHRs, care management applications, lab information systems, hospital feeds and pharmacies are often compelled to build custom interfaces, and then create somewhere for the data to go – whether in the form of new EHR fields and workflows or into a data warehouse from which they can pull the data in aggregate form to support analytics and reporting.
- Lack of care coordination and management. Value-based care requires the coordination of care across the continuum, including: stratifying patients based on risk; creating patient-centered care plans; engaging patients and caregivers alike; coordinating referrals; and addressing social barriers. These functions were previously found mostly in payer case management platforms, but with the shift in accountability and risk for populations to providers, they need to migrate increasingly to the point of care.
- Insufficient analytics. The shortcomings with data capture and interoperability described above contribute to a fourth challenge with current EHRs – a lack of tools to generate insights that will help practices benchmark and manage their populations in terms of quality and cost. Moreover, the payer claims data essential to calculating cost is absent altogether.
In response to these shortcomings, a new generation of EHRs architected for value-based care is beginning to emerge. It starts with a very different premise: that the EHR, so central during the Meaningful Use years, is now just one among many elements required to equip providers to understand and manage the cost and quality of their patients. They are increasingly characterized by innovations including:
- Making value-based care part of the design paradigm. Instead of just optimizing encounter workflows, value-based EHRs solve for the ability to understand a patient’s holistic well-being across all co-morbidities, therapies, and settings of care -- including risk stratification, integrated assessments, care planning, referral management, patient communications and team-based workflow management. This can translate, for example, into re-centering the core of the EHR around a longitudinal view that displays all the relevant components of a patient’s health journey – from office visits and lab results to hospitalizations and other adverse events - from a single screen. It also can include a built-in understanding of the clinical and financial inputs that drive quality measures, as well accommodating both in terms of structured data capture and the physician workflows to enable it.
- Building an architecture for speed and flexibility. While the healthcare system has definitively moved toward value-based care, it is also still learning how best to make the model work in practice. Therefore, public and private payers alike can be expected to innovate, and iterate, rapidly. For practices, that means EHRs built on the cloud will provide not only the ability to scale up or down without incremental investment or administrative overhead, they will enable the iteration cycles needed to stay ahead of sudden changes in requirements or regulations. This contrasts with traditional EHR semi-annual or even annual release cycles, deployed through cumbersome on-premise solutions. Furthermore, the new generation of EHRs is eschewing siloes for open, standards-based access to data as well as interoperability, so practices can integrate and interface with other sources as needed.
- Delivering new capabilities to support value-based program performance. With MIPS and alternative payment models, practices need new functionality to manage the cost and quality of their populations. New capabilities are therefore being embedded within, or connected to, EHRs. The integration of evidence-based care pathways is particularly important, enabling the EHR to reinforce clinical best practices in the context of a patient encounter, where it can most positively impact outcomes. Further innovations include the incorporation of genomic profiles facilitating precision medicine, and even advanced analytics to report on quality/MIPS measures, metrics, and risk scores in near real-time.
The acceleration of value-based care brings with it the need for practices to rethink the toolset that will help support their success. When it comes to the EHR, the capabilities of the future will center on the ability of multidisciplinary teams, equipped with powerful data and evidence-based pathways, to care for patients holistically across all health issues and care settings. While this is a departure from the office visit-centric EHRs of today, it reflects the new role of this technology as one among many important pillars forming a platform for value-based care delivery in a practice.
About The Author
Dr. Charles Saunders is CEO of Integra Connect.