- With the healthcare industry changing in a thousand different ways all at once, it’s often difficult for organizations to find an entry point into long-term strategic initiatives like population health management and accountable care.
Providers have often been faced with a chicken-and-egg problem: do they purchase health IT systems that will revolutionize workflow, or decide what changes need to be made and implement technologies accordingly?
How can processes change if the EHR can’t sustain them? How can they choose an EHR with a certain suite of functionalities if they don’t know what they want to accomplish? Either way, the investment presents a financial and cultural risk that could be disastrous if mishandled.
Part of the question may already be irrelevant for the majority of healthcare providers. Thanks to meaningful use, EHRs are largely in place across the primary care and hospital settings, and healthcare organizations are generally reluctant to rip out their health IT infrastructure at such a critical juncture in the nation’s regulatory roadmap.
The new quandary isn’t whether or not to prioritize process over technology, but how to make what we have do what we want. What the industry really needs to figure out is where we can go from here.
Wendy Vincent, Director of Advisory Services at audit and consulting firm KPMG, believes that a strong strategic vision, a firm grip on ongoing payment reforms, and health IT tools that provide data analytics capabilities to promote population health management are the three major components of successful organizational change.
Technology must play a supporting role to the human half of healthcare, Vincent told HealthITAnalytics.com in an interview, if patients are to receive the care coordination and comprehensive preventative services that they deserve.
“Most of the time, patient care is 20 percent medical and 80 percent social support,” she said. “Without incorporating holistic care management into your perspective, you might be missing some significant opportunities to head off certain issues down the road.”
“I’ve had coders tell me that they might see an elderly patient with a note about weight loss, but that’s not coded correctly, and it doesn’t get flagged for someone to ask the patient about malnourishment,” she continued. “The physician and nurses never really get to look into that, because they don’t have the right information.”
“Breaking down those siloes is a process issue. It starts with an individual or a few individuals with a vision and a strong plan that they can take across the organization. The technology is often secondary, because often times it’s really a process that’s broken.”
“An organization will just pick up a technology and try to plug a gap with it rather than ensure that they are doing all they can from a process perspective first. Technology should support the optimal gold standard in workflow, not the other way around.”
Creating a vision on paper is the easy part, the C-suite might argue, but enacting meaningful change costs time, money, and enthusiasm that can be hard to summon up in an era where a worrying number of physicians are loudly questioning why they bother doing what they have trained so long and hard to do.
While population health management initiatives that start small before building momentum have been successful for many organizations, others are still wondering where the funding and the staffing will come from, especially when these activities may take away from the fee-for-service business that still makes up the majority of reimbursements for most providers.
“I can completely appreciate that,” Vincent said. “Depending upon how large your ship is, it’s hard to make these changes. If you’re steering something the size of the Titanic, you can’t make the turn and alter courses very quickly.”
“You have to manage your fee-for-service contracts today, but you also need to start building your organization, your people, and your process for tomorrow.” Within the next three years, the federal government will be aggressively shifting healthcare reimbursements towards value-based arrangements, she pointed out, and organizations have to be ready to face that reality.
“If you’re going to successfully manage that financially, you have to begin to implement changes so that you’ve got a little bit of activity here, a little bit of activity there,” she continued. “Even if you’re doing it slowly, you’re shifting more of your care and your services into value-based care reimbursement, and winding down your fee-for-service activities.”
“That means you have to have some very provocative, bold conversations with your payers. Whether or not it’s a formal ACO with risk sharing, we’re starting to see more clinically integrated networks which are expanding very quickly, and those require a very thorough understanding of organizational goals. It means having that conversation with the payers at the table so that you can begin to share that risk and you can be held accountable for the quality.”
“That is heavy lifting,” she acknowledged, but plenty of trailblazing organizations have already shown the rest of the industry what works best to get there.
“Organizations that do this well have very clear, well-defined care plans,” Vincent explained. They know exactly what needs to happen, and they execute those strategies efficiently. They also have contingency plans. When they see a patient heading south, they have controls in place to catch that and get the person back on track. That is very important.”
Those controls often center on a robust primary care ecosystem, and may include practice transformation frameworks like the patient-centered medical home (PCMH).
“If every patient and every consumer is getting comprehensive, coordinated care, they’re going to run into fewer problems,” Vincent stated. “The patient-centered medical home is an excellent foundation for population health management. It is the basis for how you’re able to achieve success with your ACOs.”
However, the patient-centered medical home is not an easy path to follow, and many organizations believe it is prohibitively expensive. Existing research tends to come out in favor of the PCMH’s impact on quality and cost savings, but few comprehensive studies exist to accurately measure how much providers spent to get there.
“Estimated figures vary so widely, there’s almost no point in quoting them,” Vincent said. “I’ve seen studies that pin the costs at $40,000 or $100,000 per physician, but I don’t think there have been enough studies or enough research to really understand the expenses.”
“The investments are hard to quantify. It’s about the time and the education; the surveys and the tools. It’s about achieving NCQA certification, and implementing the technology that’s required to support PCMH activities. Patient portals, tapping into an HIE, and beginning to use technology to coordinate care…it’s hard to say what the true costs are.”
Organizations starting from different levels of maturity will incur different costs, she added, and certain patient populations may be significantly more challenging to manage than others.
“It’s even harder to measure the return,” she said. “So there are a lot of providers questioning whether it’s worth it to invest, because they don’t know if they’re going to see any gains. But I would say to them, ‘How can you not afford to invest in changing how you’re providing care?’ If you don’t, you’re going to struggle significantly over the next three to five years.”
Healthcare providers are already running into roadblocks, many of which have been caused by short-sighted data integrity plans or unavoidable workarounds that have forced organizations down paths they may not want to have travelled.
“We’re watching large organizations building these huge data warehouses – one client has already invested close to $300 million – and they’re still feeling confused about what their big data is and how to deal with it,” Vincent noted. All the sophisticated data analytics technology in the world can’t help a provider overcome some fundamental process and data integrity mistakes.
“If you’re responsible for coordinating care, that has to include a lot of data transparency,” she said. “If everybody has their own portal but no one shares their data and there’s no transparency, then your patients aren’t really receiving coordinated care. They’re coordinating their own care, which can be very scary and difficult for them.”
“Let’s say you fall and fracture your arm,” she continued. “What if, instead of half a dozen portals for the orthopedist and the radiologist and the primary care provider, there was one portal you could log into that is visible across multiple organizations? Your specialist could see where you got your x-rays, if you needed any blood work, and if there’s anything else going on that might affect what you need. What about physical therapy? Can that be tied into the care continuum, too?”
“Once you have a well-defined sense of the path that care needs to take, then you gather the technology you need to support it and make it happen.”
But the majority of providers don’t have the luxury of charting their own population health management journeys without paying due deference to the EHR Incentive Programs, which remain the guiding star for the health IT industry.
After collecting more than $30 billion in incentives to implement EHRs that may or may not include sufficient care coordination and risk stratification functionalities, change has slowed to a crawl as organizations wrestle with poor usability and health data interoperability woes.
“Meaningful use is here to stay, and it’s not a bad thing,” Vincent said. “It’s done a lot to bring people to the table and get them engaged because of the carrot. So sometimes it’s challenging when you don’t have the carrot right in front of you anymore, but you’re trying to work towards a longer goal and something much bigger than that.”
“The biggest step is the EHR. We’re dealing a lot with practices that are still on paper, because they walked away from meaningful use. There are some states where upwards of 30 percent of practices still have to transform. They have to go from paper to an EHR and an EHR to a PCMH in less than three years. That’s a daunting task.”
Healthcare organizations will need more than a certified EHR to accomplish their population health management goals. “In my opinion, EHRs are not able to effectively provide population health management data at an aggregate level,” says Vincent. “They do a very good job for encounters, but when you need to stratify risk, you’re going to have to invest in technology with more advanced functionality.”
“You will need infrastructure that can ingest data from disparate EHRs and pull the data up to a broader layer, so you can see what’s going on in the physician practices, the ancillary outpatient areas, the inpatient areas, the pharmacy, and much more. You get a complete view, and that’s how you can truly identify risk and head off any adverse effects.”
As public and private payers leave fee-for-service reimbursement behind, the financial incentive for securing a detailed and comprehensive view of operational and clinical progress will become increasingly pronounced. Care coordination and proactive population health management will be rewarded with cash, and providers will start to gain the wiggle room they need to get more and more sophisticated patient management programs off the ground.
“We’ve been slow, on a global level, to recognize that value-based reimbursement is the way we need to reward good behavior,” said Vincent. “We don’t want hospitals to put up a sign saying that they do the best heart surgery in New Hampshire or Oregon. Nobody wants to see that. If you’re doing a really good job you don’t want your patients having so much heart surgery, right? You want to prevent heart disease in the first place, to the extent that you can.”
“Five years ago we didn’t feel the pressure and see the shift. So the good news is we’ve made the turn. We recognize that value based care and value-based reimbursement is the right way to go, and we’re already seeing that organizations who provide high quality, comprehensive, coordinated care are going to be reimbursed more.”