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The importance in aligning healthcare IT with changes in care delivery and reimbursements

December 15, 2008

By Janie Tremlett,
Senior Strategic Advisor of Concordant

Adoption of Electronic Health Records (EHRs) has stalled at about 18 percent nationwide,
[1] giving the industry an opportunity to assess progress to-date and chart the way forward. This is a good time to take stock because changes in care delivery and reimbursements will require a more patient-centered approach to healthcare data which needs to be shared among multiple providers.
While stakeholders in the US healthcare system continue to build their own technology silos to support their individual piece of the care delivery system, the reality is that the average patient has seven providers involved in his or her care.[2]  Those providers span the care continuum and are not specific to any one healthcare facility. Today’s healthcare information systems do not adequately support that reality. As a result, momentum is building among all stakeholder groups to recognize and compensate primary care physicians (PCPs) for their essential role in coordinating care among specialists, community hospitals, large academic medical centers, long term care facilities, and other providers.
As physicians, physician groups, hospitals, and other providers plan their EHR implementations, today their primary focus is understandably on the workflow of their own practices. Their emphasis centers on capturing transactions since reimbursements continue to follow a fee-for-service model. Yet this model is shifting, bringing changes that will have a profound effect on the requirements for healthcare information systems. By understanding the nature of those changes and incorporating them into the vision of tomorrow’s healthcare information systems, the industry will be able to achieve the potential cost savings and care delivery improvements more quickly.
How can PCPs use healthcare information systems to coordinate that care – sharing patient histories, lab results, and collaborating on treatment decisions? How will they record the time they spend coordinating care so they can be appropriately reimbursed? And are current EHR applications set up to accommodate these changes?
EHRs and Healthcare Information Exchanges (HIEs) are certain to become the primary vehicles to communicate healthcare data among all stakeholders throughout the continuum of care – what Concordant calls the eCare Continuum™. The challenge for each provider is to move beyond their verticalized world focused on their specific role in the “supply chain” of patient information to think more inclusively about how patient information can be shared among all of the patient’s providers. 
To begin bridging these technology silos, patient portals are being created which essentially use the patient as the primary source and organizing principle for their medical information. For suppliers of healthcare information systems, our challenge now is how to build technology and data structures which facilitate sharing and collaboration as a fundamental part of system design. By defining the full extent of the eCare Continuum up front, we can develop systems that align with the support requirements of the more horizontal healthcare supply chain which is starting to take shape.
Changing market landscape signals major shifts ahead
Momentum is building to recognize that patient care must be coordinated among multiple providers, and the PCP is the obvious choice to be the coordinator. When the Patient Centered Primary Care Collaborative (PCPCC) was formed in 2006, its goals resonated so strongly among a wide cross-section of healthcare stakeholders that its membership now includes more than 170 employers, health plans, and health delivery organizations. 
In 2007, the call for coordination of care through the PCP was also advanced by the AAFP, AAP, ACP, and AOA[3] in their Joint Principles of the Patient-Centered Medical Home. In a statement of joint principles, these groups identified core features of this approach which focuses on quality, safety, and enhanced access to care in the context of:[4]
  • The personal physician as the coordinator of care: “each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care”
  • Whole-person care orientation: “the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals”
  • Physician-directed medical practice: “the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients”
  • Coordinated/integrated care: “across all elements of the complex health care system…and the patient’s community…care is facilitated by registries, information technology, health information exchange and other means”
  • Full-value payment reform: “payment appropriately recognizes the added value provided to patients who have a patient-centered medical home”
 
On the payment side, this approach was given a significant endorsement in June, 2008, when America’s Health Insurance Plans (AHIP) announced that it will advance a patient-centered medical home that “will replace episodic care with a sustained relationship between patient and physician. This approach redesigns the care delivery model by assessing the level of illness or disease based on sound medical evidence; promoting coordination of care; and improving accountability for outcomes, patient experience, and utilization of services.”[5] 
In May, 2007, the PCPCC proposed a hybrid blended payment model to reward physicians for prevention and coordination rather than volume of services.[6] And in April, 2008, the American Academy of Family Physicians (AAFP) published joint principles to describe a new payment structure which includes a new care management fee. 
The AAFP’s principles made a strong case for a payment system aligned with the realities of today’s multi-provider care delivery:[7]
  1. It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit
  2. It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources
  3. It should support adoption and use of health information technology for quality improvement
  4. It should support provision of enhanced communication access such as secure e-mail and telephone consultation
  5. It should recognize the value of physician work associated with remote monitoring of clinical data using technology
  6. It should allow for separate fee-for-service payments for face-to-face visits (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits)
  7. It should recognize case mix differences in the patient population being treated within the practice
These significant steps follow growing employer recognition that the nation’s healthcare systems would be more efficient and deliver better care if more attention were given to how it is coordinated among multiple providers. This consensus which continues to build among physician groups, health plans, and employers is certain to influence how healthcare is delivered. The question now before our industry is how to align technology and data to support these new directions.
Concordant’s vision for a continuum of care
To guide the next phase of healthcare information systems, we must view healthcare delivery as a continuum of care which involves all stakeholders throughout the healthcare supply chain. Employers, providers, payers, and the healthcare systems must all view their piece of the supply chain from a patient-centered perspective.    We see the eCare Continuum as an end-to-end set of technology solutions supporting a care delivery workflow rather than a stakeholder workflow.
To understand the direction for where the technology needs to go, consider the extent to which US healthcare delivery has become stovepiped. At the World Healthcare Congress Summit, Concordant led a panel discussion in which a member of the audience who leads a large system-wide EHR initiative shared an all-too-common situation: When he asked for lab results for one of his patients for tests done outside the hospital, he was told they weren’t available because they were not done in the hospital. He was told that the hospital considered that lab data “non-patient” information. Asking for clarification, hospital staff told him, “We don’t consider someone a patient if they have received care outside the hospital – even if we are treating that patient for the same problem now.” 
This doctor’s futile attempt to access his patient’s information shows that despite the clear multiplicity of providers, few of them see themselves as one element of a connected supply chain. In an era when most civilian industries have established broad, flexible horizontal supply chains, US healthcare remains very siloed and vertical.
Components of the eCare Continuum
Here are four primary components to the eCare Continuum: decision support, care management, reporting and payment. Each must include technological tools which facilitate collaborative workflow:
Care management
Including tools needed to establish communications among virtual care teams and administer care management with automated interactions to guide the workflow. Care management can also embrace ePHI exchange, patient portals, and PHRs
 
Clinical decision support
Enabling adaptable care delivery planning using a rules engine that supports the workflow of coordinated care with features including automated triggers and automatic generation of referrals
 
Payment
Including appropriate measurement and monitoring tools
 
Reporting
Featuring patient registries, data warehouses, a Master Patient Index (MPI), disease management, and quality reporting
 
 
These are the elements required to extend today’s siloed EHRs into a horizontally focused supply chain model for care delivery. Fortunately, many of the basic parameters of the EHR are already defined, and the industry has settled many interoperability issues which are the necessary technological foundations for the next steps we envision. The industry has solved how to securely pass information among the stakeholders – what is needed now is consensus on the overarching framework regarding how it will all play together.
Next steps to implement the eCare Continuum
To apply these principles in practice, first we must change the mindset of both those who purchase and those who design healthcare information systems. This involves a transition from a pure focus on “What does my organization need?” to also consider wider questions: “What does my organization need to collaborate with the other stakeholders involved with our patients?” Also, “What does the patient need?” By thinking of these cross-organizational requirements up-front, we can create more efficient designs right from the start. This will also avoid the considerable re-work and retrofitting that would be required to connect one silo to another silo. 
This can build on and extend our current focus on interoperability standards and transactions connecting the silos. It requires shifting and adapting interoperability standards to fit into the context of a patient-centered workflow extending from patients across all their providers and all the way through the payment side of the continuum. We can build on the successes of many pilots which have already been initiated using current technology.
In the next phase of implementing EHRs and HIEs – the building blocks that enable the collaborative communication – we must think about how each of the four areas we outlined above can support the evolving model of care delivery and payment:
  • How can we build clinical decision support systems which span multiple providers?
  • How can we orchestrate the workflow across multiple providers and involve the patient –when it is still expensive and challenging for a single provider to adopt the EHR?
  • As reimbursements shift from siloed, service-based fees toward care-based fees, how can care management systems maximize both care and payments? 
  • How can reporting and payment systems be structured to accommodate both traditional and new reimbursement models?
The answers to these questions are just in the formative stages yet the current EHR and HIE deployments are occurring without this eCare Continuum context. We need to make a shift in how these deployments are being implemented before it becomes too expensive – and risks creating barriers to future care delivery.

Concordant (www.concordant.com) is an eHealth Services firm that engages with healthcare organizations to plan, implement, and manage their HIT (Health Information Technology) infrastructure. Our unique methodology combines an ideal balance of tools, talents, techniques, and cost management. Healthcare IT leaders who are responsible for creating and maintaining a dynamic HIT infrastructure have a reliable partner in Concordant. Hundreds of healthcare organizations rely on our advanced techniques and experienced staff to provide reliable and optimized services for the entire HIT lifecycle to ensure that they have well-designed, efficiently operated technical environments.
 
To reach this author, contact Janie Tremlett at
jtremlett@concordant.com.  To learn more about Concordant, visit www.concordant.com


[3] American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association
[7]http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File.tmp/022107medicalhome.pdf
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