Provider communications in a risk-based world

Nov. 17, 2016
Kathleen Aller, Director of Business Development for HealthShare, InterSystems

A recent HIMSS Analytics study confirmed that risk-based population health management programs are gaining traction in the hospital ecosystem and are expected to continue to proliferate in the years ahead.1 Many consider these shared contracts to be essential to value-based care success, where payers and providers agree on which services should be given based on a population’s health status. In order for these contracts to be successful, however, consistent communication and tight-knit coordination across the healthcare community is critical to ensuring that the right care is delivered to the right population at the right time.

Let’s take, for example, an accountable care organization (ACO) that is trying to improve care quality for patients with type 2 diabetes. The payer and provider groups may agree that these patients should be seen by both a primary care physician and an endocrinologist every three months to ensure adherence to medications and exercise programs, and that any unforeseen health complications are being addressed in a timely manner.

To help foster this collaboration and engagement, the payer may also need to make technology decisions to help care teams receive comprehensive, timely health information updates directly at the point of care and within their existing workflows. This would enable providers to make better clinical decisions and would help members better understand and more appropriately manage their health beyond the four walls of the care facility.

So why haven’t more healthcare organizations taken advantage of these information-sharing opportunities, especially if they would assist with value-based care initiatives and risk-based contracting?

Right technology, wrong care model

As it stands, payer and provider organizations have made extensive investments in both operational and analytical information technologies. The problem is, most of these systems were designed for what is becoming an outmoded model of care. They were engineered to capture detailed charges and process claims when high service volume was positive. They focus on high-intensity services delivered in acute care settings. And they treat each participant in the value-based care delivery process as an individual player, rather than an integral member of a multi-disciplinary team.

While we still need these kinds of operational systems, they are insufficient for the collaborative community-wide approaches to care required under value-based payment models. Traditional health information systems are capable of sending documents and data to one another, but they aren’t designed to support comprehensive, longitudinal healthcare records with the full complement of clinical and administrative information required to identify gaps in care, ensure smooth transitions between care settings, and empower patients and family members to manage their own health.

When financial success depends on delivering care in the lowest intensity setting, minimizing hospitalizations, and keeping people healthy and injury free, EHRs and payer claim systems are inadequate. The local Meals on Wheels program may be essential to keeping elderly patients out of the hospital, but it won’t base its operations on an EHR. Similarly, holding a primary care physician accountable for a patient’s influenza vaccine status is difficult when he or she has no visibility to the flu shot obtained at the local pharmacy – though the payer will eventually know about it when the claim arrives.

Common communication hurdles

Payer and provider organizations that rely on siloed EHR and claim systems encounter some fairly common communication barriers. These include gaps in the record, data received too late to be of value, and information that is so hard to find it’s overlooked in the bustle of time-pressured care settings.

Unless everyone involved in the care process is connecting and contributing information to a common record, important data may be missing, and each participant in the care process will be left with an incomplete picture of the patient. Similarly, it is difficult for patients to understand their own health histories when information is siloed. Data currency is just as important as ensuring that information is comprehensive. If there is a gap between when important information – such as a test result – is created and when it becomes available to providers, patient safety is put at risk and the opportunity for timely intervention is lost.

Equally frustrating is when providers, who already have too many competing demands on their plates, are forced to hunt down patient data or miss an important finding that is buried in obscurity. To be useful, actionable information must be integrated into existing care delivery workflows and presented at the right time in ways that are meaningful to each member of the care team.

The recent KLAS Research report, “Interoperability 2016: From a Clinician View – Frustrating Reality or Hopeful Future,”2 provides some insights on these communication hurdles. KLAS, a well-known and highly respected health IT research institution, took an in-depth look at clinical information sharing among providers and hospitals that are using EHR platforms. The analysis specifically looked at how these systems’ communications capabilities (or in some cases, lack thereof) either improved or impeded patient care delivery. One of the key findings in the report is that, while the capability to exchange information is in place and becoming more widely used, shared information is only making a real difference to care in limited circumstances.

But, what is still more disturbing is that the information exchange discussed in the KLAS report is what we might term the “easy” stuff. This is information exchange between physicians, and between physicians and hospitals, for the care of individual patients. These are the portions of the care provider ecosystem with the most mature EHR functionality; those in which the U.S. government has invested billions of dollars to promote EHR adoption. But as we’ve already pointed out, they are only a small portion of the provider team in a value-based health and care system.

Whole-person IT

The concept of value-based care is that we should pay for outcomes, not service delivery. This requires a holistic approach to care, and a holistic view of patients and the population cohorts of which they are members. From an IT standpoint, this means the record of care can’t be centered around any one facility, provider, or payer, but rather, it must be centered on the patient. And the circle of caregivers contributing to, and drawing upon, that record must be enlarged.

Consider this: the information sharing environment depicted in the KLAS report could be pictured as a three-way relationship – patient, hospital(s), physician(s):

Payers are missing entirely from this environment, which assumes information is shared purely for payment and auditing purposes. The partnership implied by value-based contracts and risk-sharing agreements requires at least this:

But we can’t really manage outcomes for a managed care or bundled payment program without expanding the circles yet further to include ancillary, post-acute, and other formal care providers.

Finally, consider those who make it possible for the elderly to remain in their homes, safely; for children from low-income communities to receive preventive health screening; for those with mental illness who are incarcerated to be connected with their care management teams; for all those with chronic illness whose family or friends provide informal care and care management. It is these care team members who are often most critical to keeping costs and care under control, and who are least likely to be connected to traditional health information systems.

The comprehensive virtual health and care record should include all patient information across the care continuum – problems, allergies, medications, prescription data, lab results, claims, history and physical notes, social service information, diagnostic images, and remote monitoring device data, just to name a few. It will be in a variety of formats – documents, structured codes, images, text, and messages – that will need to be organized, structured, interpreted, normalized, and presented to providers in a form that makes it useful for care management. This all needs to be done in near real time – not days, weeks, or months after an event occurs – to ensure that the highest quality of care is being delivered in an efficient manner.

Making the record work

A comprehensive virtual health and care record is the foundation for value-based care management, but it needs additional infrastructure to be effective. Identity management is a critical component to enabling provider communications, both with patients and with other providers. This includes correctly identifying and linking together all records related to a given individual. It includes accurately connecting patients with their authorized care representatives. It also includes a comprehensive provider directory and care team listing, associating patients with their providers, provider affiliations, and payer networks.

Even more critical is that the record include the intelligence to dynamically recognize and identify population cohort members as clinical and demographic conditions change. For example, when a lab result moves a diabetic patient into a high-risk category – or a new weight status causes a patient to be seen by a primary care provider more frequently – each member of the care team should have instantaneous access to the health status update. This kind of active intelligence is the heart of population health management.

Achieving quality-care goals

The overall goal of improving communications across the health and care communities is to increase engagement and decrease the risk within a value- or risk-based care contract. Provider engagement, active participation, and partnerships with other clinicians should be a natural result of these contracts, but it won’t happen without a shared patient record. Similarly, patients who are part of a shared decision-making process, with full visibility into their own health information and care plan, are more engaged and less likely to require higher intensity services. To keep both providers and patients engaged, we need to make sure that shared information is meaningful, communications are streamlined, and efficient, high-quality care is enabled.

As we continue to see the U.S. healthcare system shift to more value- and risk-based models, the need for effective healthcare communications is more critical than ever. By expanding the conversation to all healthcare stakeholders, enabling interoperability and provider communications across health networks, healthcare institutions will be in a better position to succeed in these care contracts both now and in the years ahead.



Sponsored Recommendations

The Crushing Weight of Healthcare Cloud Compliance & Security Debt: Perspectives & Strategies

Discover how to navigate the pressing challenges of healthcare cloud compliance and security. Join industry experts as they unveil key insights and actionable strategies to break...

Telehealth: Moving Forward Into the Future

Register now to explore two insightful sessions that delve into the transformative potential of telehealth and virtual care management solutions.

Telehealth: Moving Forward Into the Future

Register now to explore two insightful sessions that delve into the transformative potential of telehealth and virtual care management solutions.

How Gen AI is driving efficiency in the ED

Discover how Gen AI is revolutionizing efficiency in the Emergency Department (ED), enhancing patient care, and alleviating staffing challenges. Join Microsoft and Valley View...