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    Charles Saunders
    Charles Saunders, MD

    During the fee-for-service era, EHRs rose to prominence as tools to automate documentation of patient encounters, then inform subsequent billing workflows. 

    With the continued growth of value-based care, however, administrators are finding that their practices’ areas of focus are beginning to change dramatically. MGMA’s 2018 Regulatory Burden Survey not only captured the frustration felt as practices get their arms around MIPS and emerging alternative payment models (APMs) — cited by 88% as “very or extremely burdensome” — but also the increasing pains attributed to their EHRs, led by a lack of interoperability (80%) and need to accommodate new government-imposed requirements (77%).   

    It makes sense to address this growing challenge by looking at what practices are now expected to solve. To optimize performance under the Merit-based Incentive Payment System (MIPS), APMs and commercial value-based reimbursement models, practices have become accountable for demonstrating high quality of care while also reducing cost. This, in turn, has elevated the need to track and measure against a host of new performance metrics, which then need to be documented and analyzed on a near real-time basis. 

    The resulting insights must enable practices to identify negative outliers and manage them on an individual and collective level to optimize overall performance. In addition, certain APMs and value-based models require collaborative, team-based care. As care planning, patient navigation and care coordination are added in a practice, they must be integrated with point-of-care workflow. 

    These new marching orders do not match up well against the infrastructure that practices have at their disposal today. There are many new capabilities needed to optimally align with value-based mandates, including population health management, data management and reporting and financial risk management. The EHR remains an unavoidable linchpin to ensuring that practices will be able to achieve more efficient operations and improved clinical outcomes despite not being designed for such a role. 

    When evaluating the ability of EHR technologies to address value-based models, practices should look for these key attributes:

    • Secure and efficient data management and reporting. To successfully comply with MIPS, APMs and commercial value-based reimbursement models, practices are required to report on a variety of quality measures based on EHR inputs. Unfortunately, the data fields in legacy EHRs are often limited or not specialty specific, resulting in essential data elements being documented in unstructured fields, if consistently documented at all. In addition, many EHR legacy architectures are not designed for ease of data access. In many cases, vendors may create barriers to access or create onerous financial hurdles. In the near term, pragmatic practices can turn to manual chart abstraction to plug data gaps. To be sustainable, practices must advocate that EHR vendors better align structured fields with the reporting requirements of prevalent value-based models, as well as facilitate the extraction and packaging of data for quality measure submissions.
    • Ability to manage holistic patient care outside the office setting. Value-based care is compelling specialists to assume responsibility for managing the quality and cost of patient care across the care continuum. This requires the use of evidence-based care pathways, coordination of patient care across all care settings, identification of trends that could indicate declining health outcomes and proactive interventions to reduce the risk of avoidable adverse events. Because legacy EHRs were built around office encounters, they often do not support EHR-to-EHR data exchange and offer limited visibility into comorbidities and alternative care sites. Practices need value-based EHRs to be open and interoperable by design, with bidirectional data and workflow encompassing a suite of complementary solutions — from care management to hospital ADT feeds — that can illuminate all the interactions a patient has across the healthcare system.
    • Real-time performance management. Under MIPS and other Advanced APMs, the quality and cost performance results delivered by CMS are two years retrospective. Without real-time analytics to provide up-to-date insights into quality measure performance, any documentation or performance gaps may not be uncovered until it is too late for practices to adjust. EHRs must feed into analytics capabilities that draw from a variety of systems to expose and later predict positive and negative impacts on performance at patient, provider, practice and population levels.

    Evaluating the ability of an EHR to support value-based success requires a checklist of tailored features that it must deliver for practices. The following emerging capabilities are important:

    • Care management tools. To optimize clinical outcomes while minimizing costs, specialty practices will be expected to adhere to evidence-based pathways and mitigate avoidable adverse events. EHRs can advance these efforts by enabling stratification of patients based on risk; assessing patients for unmet needs, creating care plans and arranging task lists and workflows; integrating evidence-based pathways with compliance tracking; then facilitating patient communication to support. While these functions have typically fallen into the realm of payers or been delivered by separate point solutions, the shift in financial risk to providers now necessitates their inclusion in the EHR.
    • Cloud-based architecture. Value-based models are relatively new and therefore subject to rapid change as they mature. To keep up, practices must ensure their vendors are able to quickly update EHR data fields, features and workflows to support the evolving demands of a variety of public and private reimbursement models. Also, the complexity of modern systems and increasing security requirements make it difficult and costly for practices to deploy and maintain on-premise applications. This favors cloud-based EHRs that can be modified once and pushed out universally, minimizing the waiting time for practices to adjust and comply. Most cloud-based EHRs can also be counted on to support the access and interoperability that practices need to pull data, submit reports, connect to complementary systems and generate insights.   
    • Patient-centric workflows. While legacy EHRs often conceived encounters as physician-centric — from intake to visit to check-out — value-based EHRs must feature workflows that support more holistic care at every step. For example, physicians can more efficiently manage the quality and cost of care when presented with a single, longitudinal view of patients that displays all the relevant components of their health and well-being — from office visits and lab results to adverse events. In some specialties, the ability to identify patients for appropriate clinical trials at the point of care and/or view genomic attributes and kick off individualized treatment regimens will help practices advance toward a vision of precision medicine that ensures the best possible quality and cost of care.

    Value-based care is transforming all the pillars of the fee-for-service world and the central role of the EHR in practices is no exception. Whereas that technology once primarily served to enable consistent clinical documentation, it is fast becoming essential for the capture, centralization and actionability of holistic patient data. Practices that are proactive in driving the shift will support better outcomes for their patients — and improved performance across their value-based initiatives.

    Charles Saunders

    Written By

    Charles Saunders, MD

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