Charles Saunders, MD

We recently convened a convention room full of leaders from independent physician practices nationwide and asked them if they believed value-based care was here to stay. Eighty percent said yes.  With that in mind, we then asked them what was most likely to keep them up at night throughout 2018.  Their top answer: transforming their practices to better manage care quality and cost-the core requirement for 

While this level of focus and commitment is heartening, the reality is that most practices aren’t ready to deliver. Skills, staffing and workflow are all issues, and, understandably, the majority of practices are also 

hoping to make do with the technologies they have today

 vendors encourage the perception that their applications can remain the centerpiece of practice technology in the era of value-based care, as they often were during the days of Meaningful Use.

Not so. Keeping in mind that the core mandate of value-based care is shifting accountability to providers for the holistic quality and cost of the care they deliver, five shortcomings of legacy EHRs become apparent:

1)     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. They often do not capture the information needed to report for the Merit-based Incentive Payment System and alternative payment models-such as comorbidities and progress against evidence-based care pathways.

2)     Interoperability is poor. While EHRs tend to be the primary application at the point of care, they do not connect to emerging technologies that primary care physicians (PCPs) increasingly rely on to gain a holistic view of patient well-being. For example, integrating with other EHRs, care management applications, lab information systems, hospital feeds and pharmacies requires not only custom interfaces, but somewhere for the data to go in the form of new EHR fields and workflows.

3)     EHR analytics are incomplete. Value-based care requires providers to benchmark and manage their populations in terms of quality and cost. Quality measure reporting from the EHR is limited by the volume of unstructured-or simply uncaptured-clinical data, while the payer claims data essential to calculating cost is absent altogether.

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4)     Patient portals do not equal patient engagement. Legacy EHR portals made visit records and secure communications available to patients. However, value-based care requirements mandate not only a direct and interactive exchange with patients to ensure progress against care plans, but consistent, real-time access to address emergent symptoms and transitions in care.

5)     Fee-for-value workflows are broader and more complex than an EHR can support. The interaction between PCP and patient in an office setting is critical, but value-based care requires a cohesive workflow that involves all the members of a care team across all settings and into the patient home.

While a new generation of EHRs architected for value-based care is poised to emerge, most practices have already made significant investments in their legacy solutions and are not in a position to change. However, as providers participating in alternative payment models such as the Oncology Care Model know, payers will expect-and fund-new capabilities to support their practice’s transformation. What should practices therefore prioritize to meet reporting requirements, improve operational efficiency and increase revenue in the years ahead?

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1)     Data aggregation and analysis to enable a holistic patient view. The data required to assume accountability for patient care across settings and comorbidities lies locked in multiple siloes today. That’s why the foundation of any practice in the value-based care era should be data exchange technology that can pull from disparate systems, including EHR, payer claims, labs, Rx, and more, then clean and normalize it. Once transformed, the data can be used to document performance measures, calculate risk scores, report to registries and enable advanced analytics to understand and predict the health of patient populations.

2)     Care coordination and management to positively impact cost and quality drivers. Fee-for-value performance depends on minimizing those adverse events that data show to have the greatest negative impact, especially unnecessary emergency department visits and avoidable inpatient stays. Care management applications, once the domain of payers, are an important feature of the practice landscape in order to support effective navigation and evidence-based care planning across multidisciplinary teams.

3)     Revenue cycle management (RCM) focused on alternative payment models and risk. In the fee-for-service era, RCM equaled a rigorous focus on getting claims paid faster and more accurately, while removing administrative burden. Value-based care has changed this mainstay, too. Practices now need RCM at the forefront of their financial planning. This means forecasting performance against both traditional and alternative payment models, while managing risk and shared performance incentives to ensure overall health. It is also essential to manage complex reimbursement calculations, driven by cost and quality outcomes that are variable across payers.

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Smaller practices that lack the resources to make these investments solo should look for opportunities to band together in geographies, payer networks or even specialty associations to share infrastructure-ideally, as part of an alternative payment model effort of their own.

The acceleration of value-based care brings with it the need for practices to rethink the skills, teams, workflows and toolset that will help carry them to success. The EHR, so central during the Meaningful Use years, is becoming just one among many elements required to equip providers to understand and manage the cost and quality of their patients. The capabilities of the future align around the ability of multidisciplinary teams, equipped with powerful data and evidence-based pathways, to care for their patients holistically across all health issues and care settings. While the journey may seem daunting, it is one that is both worthwhile and necessary to embark upon as the healthcare system increasingly shifts toward value.

Charles Saunders, MD, is the chief executive officer of Integra Connect.

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Keeping in mind that the core mandate of value-based care is shifting accountability to providers for the holistic quality and cost of the care they deliver, five shortcomings of legacy EHRs become apparent.

Author | Charles Saunders, MD

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