Do-Over: Reengineering Your Electronic Health Records System to Drive Value-Based Care Success

Over the last decade, electronic health record (EHR) systems have taken a major beating. They have been blamed for physician and nurse burnout, the loss of the personal connection between clinicians and patients, making documentation twice as long (and half as effective), and a host of other issues in healthcare.(1-3)

As we move from fee-for-service to value-based care, EHRs have tremendous potential to ease that transition.

Most of the problems are not driven by the EHR systems themselves, however. Instead, they are driven by the haste with which those EHR systems were initially implemented. Now the healthcare industry has an opportunity for a major do-over. As we move from fee-for-service (FFS) to value-based care, EHRs have tremendous potential to ease that transition. In fact, the good news is that most of the capabilities required to enable value-based care and reimbursement are either already built into EHRs or are being incorporated into them daily. There is no need to completely replace them with yet another technology. The challenge is in re-thinking and re-engineering those systems to optimize them for a value-based world. That will be no small task.

Designed for Encounters

When EHRs were first introduced, they were created for the FFS world. It made sense then, because that was how nearly all care was reimbursed. The problem is that those processes, workflows, and methods of reimbursement are not configured for the requirements of value-based care, such as value-based contracts, social determinants of health tracking, care management, and other aspects that are focused on the long-term health of individuals and populations. As a result, they don’t translate very well.

For example, suppose a patient with diabetes comes to see her primary care physician (PCP) for a routine follow-up. In reviewing her record, her physician notices that she is overdue for a diabetic retinal examination. That alone is more luck than a concerted effort to make sure all the patient’s health needs are met.

The physician’s office is capable of administering that examination while the patient is there. Because FFS is based on encounters, however, the practice would lose money if the diabetic retinal examination were administered as part of the routine visit. There is no way to enter the information in the EHR in a way that allows the practice to be reimbursed for both services at the same time, so the patient is told she must make a separate appointment for the eye examination That is less-than-optimal care, and certainly poor customer service. But it is based on the practice’s business needs.

If the EHR is optimized for value-based care, however, it would provide a mechanism for both the routine visit and retinal examination to be credited during the same visit. It also would be re-tooled to use all the data available to proactively uncover and call attention to that missing examination (and any other care gaps the patient might have) to encourage closing of as many gaps as possible when the patient is there in the office.

Gaining a Better Understanding of Risk

One of the most important reasons to optimize an EHR for value-based care is to gain a better understanding of and, ultimately, stratify the risks within a practice’s various populations. To do that, practices must gather more and better data on their patients so they can apply predictive analytics with greater reliability.

If the EHR is set up strictly to manage encounters, as most FFS-oriented EHRs are, the practice is unlikely to collect those data. The EHR will be focused on closing out the encounter, and will contribute little to managing other factors that could be affecting a patient’s health, or reaching out to patients who should be coming in for tests or health maintenance activities.

Take, for example, a patient who comes in for an annual physical and complains of occasional chest pains. The patient is healthy otherwise, but just to be safe the PCP refers the patient to a cardiac specialist, who diagnoses that the patient has an atrial fibrillation along with high cholesterol. These are significant issues that should automatically raise that patient’s risk score, resulting in an elevated level of care as well as higher reimbursement under the terms of a value-based contract.

If the EHR is not set up for the PCP to automatically or easily add that referral and diagnosis to the patient’s problem list, it may not get included as part of the patient’s risk score.

The bottom line is that if an issue isn’t shared properly, and automatically, across providers, it doesn’t exist within at least one of the EHRs. That makes it difficult to care for the patient properly, and to receive the full reimbursement to which providers are entitled.

Factoring in Social Determinants

At their essence, risk scores are a measure of the degree of difficulty or level of effort required to bring a patient to a better level of health (or, in some cases, prevent a patient from reaching a higher level of acuity). In recent years, the healthcare industry has begun to understand and document the role social determinants of health (SDoH), such as the inability to afford or find healthy foods locally, housing instability, lack of transportation, and so on play in a patient’s overall health.

Again, EHR systems that were originally designed for FFS encounters usually are not set up to capture or use this information. The ability to add to diagnosis codes for services that address SDoH can change this. Redesigned documentation and workflows that facilitate the documentation of SDoH screenings will be the “new normal” in a value-based care environment.

One way to capture SDoH now—and outside of the patient encounter—is to encourage patients to complete these screenings prior to the visit. Practices can include an autogenerated previsit questionnaire within their patient portals that patients (or their caregivers) are requested to fill out when scheduling visits or checking in online. This method not only gives the patient time to think about the answers, but also saves staff time, and may solicit unbiased answers from the patient. The answers captured from the SDoH template then autopopulate the social history on the patient’s record and can be associated with the appropriate ICD-10-CM code.

If the questionnaire is set up to capture the answers as discrete data, the results can be fed into the practice’s analytics and used to trigger messages or alerts in the EHR to explore critical topics in more detail. It also can provide physicians and other clinicians with more context about the patient that will guide them in making better clinical decisions and addressing their social needs.

Getting Started—Growing By Cutting

The first step in optimizing an EHR for value-based care is to do an assessment and analysis of the current insurance contracts and future business model to understand how much revenue is coming from FFS, and how much is derived from value-based contracts. The goal is to maximize revenue now, while looking forward to future value-based care and growth potential. But obviously, the more risk an organization has taken on through the value-based care contracts, the greater the urgency to optimize the EHR. Failure to capture data that expose vulnerabilities can have a significant impact on the bottom line.

Failure to capture those data also can hurt the practice later, when it is time to renegotiate those contracts. The ability to prove that the work put in to improve patient or member health has produced significantly healthier populations and prevented patients and members from moving to the next highest risk level will put the practice in a much stronger negotiating position when the current contract period is expiring.

Even those organizations that are still primarily operating fee-for-service, however, will want to begin moving ahead. Optimizing an EHR, and a practice for that matter, for value-based care can have a long change runway. For those who have the option, the best time to get started is a year or two before value-based reimbursement accounts for a significant portion of their revenue.

Once the organization fully understands its exposure, the next step should be to take a hard look at processes and workflows to see which can be amended, simplified, or eliminated entirely. This will have the dual effect of making the practice more efficient and increasing buy-in from clinicians as they recognize the practice is not looking to add to their burden but, rather, wants to make their lives easier.

The same is true with documentation, one of the strongest hot-button issues among physicians especially.(4) As more of the care shifts from FFS to value-based care, the practice should be looking at what documentation is no longer necessary, or is largely duplicative of newer requirements, and eliminating it from the workflows.

Finally, there is the issue of access. It’s no longer good enough for patients to have to wait several weeks to see their PCP. Patients are consumers, and must be treated as such. We want our patients to be seen whenever they want or need to be seen. This means scheduling systems and processes must be optimized so patients can see their PCP or provider team member the same day when sick or within a week when well.

Employ Analytics

As more of the practice becomes tied to value-based reimbursement, the next step in most cases will be to implement a more powerful set of analytics for population health management. This is where the EHR can become a powerful ally of physicians and the practice as a whole by supplying real-time dashboards of important metrics at both the practice and patient level.

Most EHR systems come with some basic analytics, but some practices will want to go well beyond those capabilities. For example, EHR analytics can show which members of a practice’s diabetic population have the highest utilization of emergency department (ED) and inpatient stays. Clearly these patients fall into the “high risk” category and need to be managed more proactively than those in lower risk categories.

Analytics allow a practice to stratify groupings of patients to ensure precious RN resources are targeting the correct groups with the most appropriate levels of interventions. There often are divisions even within the high-risk group. Some patients may have only one or two care gaps, and be at their stable optimum health. Others in that group may have recent hospitalizations, or changes in their conditions that cause them to be unstable and vulnerable. These may be the patients to focus the highest level of care management services on.

We want patients to return to their optimum health, even within their high-risk status. Team care and patient engagement are necessary to help patients through these unstable periods. It is crucial during times of transition to ensure patients’ needs are met by utilizing intense care management to avoid unnecessary ED visits and rehospitalization.

Patients in the lower-risk groups also require targeted intervention to ensure they maintain their health status. Ensuring that patients do not rise to the next risk level is perhaps the greatest opportunity of healthcare savings. These interventions typically are completed by nonlicensed personnel, or even system automation. For example, if you are filtering on diabetes, the patients whose diabetes is well controlled may need reminders to complete their annual retinal eye examination or perhaps to go for a missed lab test. These types of interventions help support patients in managing a lifetime condition and decreasing the risk of escalation of the disease.

Quality analytics can help determine where the needs are, what types of needs they are, and who can best fill those needs. It may lead the practice to realize it must hire more RNs for care management, or redesign workflows to ensure everyone is working at the tops of their licenses, or make other important changes. It all starts, however, with capturing accurate, usable data in the EHR.

Take a More Team-Based Approach

Physicians are trained from day 1 in medical school to be independent warriors. But that approach isn’t practical in a value-based, population health, patient-centric world. It may not take an entire village, but it takes a strong team to empower patients to become and stay healthier.

Physicians and nurse practitioners lead the team, focused on assessing, diagnosing and ordering treatment. RNs, LPNs, MAs, and other nonlicensed personnel communicate with patients, review reports in the EHR, and handle other care management tasks. A well-designed EHR can enable the care management process to function properly by making it easy for the care team to see and share critical information.

Get the Patients Engaged

The final consideration in launching an EHR optimization program is how to do it in a way that gets patients engaged and participating in their own care. Committing to an “open notes” concept is part of it. And yes, this can be a culture shock to some healthcare professionals. But giving patients easy access to their own information through a secure patient portal offers a tremendous means of activating them.

As mentioned previously, the patient portal also offers many opportunities for engagement as well as data capture. The more patients can be encouraged to use it, refer to it, and share information in it on a regular basis, the more effective practices will be in managing the most difficult and unpredictable element in value-based care–patient behavior.

Seeing the Benefits

How long will it take to see the benefits of optimizing an EHR for value-based care? It depends on the practice and how far along it is in its transition. But since value-based care requires risk stratification partnered with strong workflow processes and planned interventions to help improve health (as well as reimbursement), the deeper the practice is into value-based care, the faster it will reap a return on investment. For those who are just entering into their first value-based contracts, or perhaps considering it, starting now will position an organization to achieve those benefits much quicker.

And make no mistake: no matter what controversies may be out there, value-based care is the future of healthcare. Which means this is the ideal time to optimize your EHR.

References

1. Reith TP. Burnout in United States healthcare professionals: a narrative review. Cureus. 2018;10(12): e3681.

2. Gorn D. These doctors think electronic health records are hurting their relationships with patients. PBS.org, July 2017. www.pbs.org/newshour/health/doctors-think-electronic-health-records-hurting-relationships-patients .

3. Scott DJ, Labro E, Penrose CT, Bolognesi MP, Wellman SS, Mather RC 3rd. The impact of electronic medical record implementation on labor cost and productivity at an outpatient orthopaedic clinic. J Bone Joint Surg Am. 2018;100:1549-1556.

4. Gawande A. Why doctors hate their computers. The New Yorker. April 24, 2019. www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers .