To help physicians, EHRs must adapt to value-based care

There is growing concern that electronic health records (EHRs) will not meet physicians’ needs in a value-based care environment, especially as the federal government moves forward with Medicare payment reform, promoting safer, more effective care while controlling costs.

Commercial insurers likewise are pursuing value-based models as a way to more effectively promote high-quality care. They seek more efficient and affordable care by adopting models similar to accountable care organizations and by using core quality measures in their programs.

“What I’m hearing from clinicians about what they need from EHRs and value-based care is pretty simple: They want anything that will improve” their patients’ health, says Kate Goodrich, MD, MHS, director of the Center for Clinical Standards and Quality and chief medical officer for the Centers for Medicare & Medicaid Services (CMS). “If that means digitized health data, then that health data needs to be accessible no matter where or when it is needed. If that means quality measures, then those need to be applicable, outcome-based, and with reliable feedback that shows the clinician how to improve.

Health IT, including EHRs, is instrumental in making value-based care work. But simply having an EHR in place won’t be enough to support value-based care, experts say. EHRs must be fine-tuned, with all the available functions, integration points and automation needed to deliver the right information at the right time enabled. Moreover, experts say physicians should ensure that they not only optimize their software but have successfully integrated it into their practice workflow.

“Moving [to value-based care] is a difficult transition for most small practices to make, and even for some large organizations to make as well. It’s complicated, but EHRs allow us to deal with complicated data in a more streamlined way,” says Stephen Beck, MD, FACP, FHIMSS, an internist and former chief medical information officer at Cincinnati-based Mercy Health, who is now a consultant with BecTech LLC.

MACRA requirements

To better optimize EHRs for value-based care, physicians first need to verify that their existing system offers (or can soon have via an upgrade) the reporting capabilities needed to meet the requirements of the Medicare Access and CHIP Reauthorization Act (MACRA), says Mark G. Weiner, MD, FACP, FACMI, a primary care physician at Temple General Internal Medicine Associates in Philadelphia. But he also recommends
investing in EHRs that have more advanced reporting functions.

“Investments need to be made in the type of reporting that not only meets the need of the MACRA quality reporting requirements, but also the kind of reporting that can help you anticipate and address the specific needs among patients who are failing and perhaps even looking out for people [with chronic conditions] who have been well controlled but who maybe turning the corner in a bad way,” he says.

According to Richard Loomis, MD, vice chair of the Healthcare Information and Management Systems Society (HIMSS) Electronic Health Record Association, EHRs that are 2015-certified will meet the quality reporting requirements.

Loomis, who is also chief medical officer and vice president of informatics for EHR vendor PracticeFusion, says this certification criteria will be important for participating in the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APM) payment tracks that are part of MACRA. 

EHRs need analytic capabilities

Health IT experts suggest that physicians ask whether their EHR has the analytics capabilities to allow them and their staff to study patient data to gain insights, such as unique circumstances that prevent certain patients from achieving their desired health outcomes. 

Weiner explains that such capabilities help physicians see trends among patients who may need different or additional treatments or care approaches to meet outcomes specified under value-based care models. 

In addition, Weiner says, physicians should determine whether their EHR enables them to identify patients who, based on data such as missed appointments or troublesome biometric measures, might be facing a predictable medical issue. 

“It’s one thing to report that 70% of your panel is meeting criteria. It’s another thing to help the doctor drill into that panel to understand the nature of the problem that the patients are having: [For example,] are people not succeeding despite being on a number of medicines? Or are they not succeeding because they haven’t shown up to the last several visits?” he says. “We need a system that better identifies the people who are not succeeding so we can tailor the appropriate intervention to improve the overall score. That’s the next-level stuff.”

Check the vendor’s roadmap

Zeshan A. Rajput, MD, MS, director of business intelligence at South Shore Health Systems in Weymouth, Massachusetts, suggests that physicians ask their EHR vendors about specific analytics and reporting features. 

He also advises physicians to ask about any additional functions that the vendor is planning to add to better aid physicians and what support they will offer physicians to implement these functions and integrate them into their practice protocols.

“I should be able to say to my vendor, ‘What’s your plan?’ And vendors should have the option to say, ‘This is how we’re going to do it internally’ or ‘This is who we’re partnering with,’” he says. “But having no plan at this stage of the game is a concern.”

Loomis advises physicians to read the fine print to ensure they understand what their vendor plans to deliver to avoid any misunderstandings or misconceptions about planned additions.

He notes that vendors who are members of the HIMSS EHR association “typically encourage buyers to carefully review vendor contracts for inclusion of these promised enhancements, and talk to their peers who are also customers of the vendor they select to determine how well those commitments are met.”

Using EHRs to drive value-based care

Rajput says the value-based models help doctors provide better quality care without unnecessary tests and procedures. “That’s just good common medical sense. That’s something we were all trained to do,” he says. 

Now, Rajput says, physicians must use their EHRs to support that vision of care. For example, he says, if a physician is examining a patient for a possible respiratory infection, the EHR should offer up a chest X-ray done last week, as one that recent may be relevant. But the EHR won’t offer up every chest X-ray the patient has ever had (as is sometimes the case with EHRs today).

Rajput, who moderated a panel on EHRs supporting value-based care at the American College of Physicians’ Internal Medicine 2017 meeting in April, says leading EHR vendors are developing tools within their systems to show physicians the data they need to deliver value-based care. He expects EHR vendors in the next few years to roll out systems that will identify key information that physicians need based on notes about a patient’s condition.

Rajput says physicians should be asking their vendors when this and other emerging functions will be available on their systems. He says physicians who find that their vendors aren’t developing such features, or can’t provide a timeline for such advances, need to think about switching to an EHR vendor that has these features in the works. 

Health IT experts acknowledge that moving to a new EHR can be an expensive and onerous process, but say that doctors whose existing EHRs aren’t offering advanced capabilities will likely find that they’ll have a harder time participating in value-based care.

Weiner, a panelist at the ACP presentation, says EHR vendors already offer functions that are critical to supporting value-based care. He points to systems that have physicians justify the need for expensive procedures such as an MRI by taking them through a series of steps, similar to checklists already used for prior authorizations. He says such features automate what physicians can do manually, although he and others note that the automated system better ensures that physicians follow all the appropriate protocols and that those protocols are based on current standards.

Goodrich says she sees EHR vendors responding to what physicians have said they need to succeed under a value-based care model. 

Obstacles to overcome

Although EHR vendors will continue to add functions to support value-based care, health IT experts cite challenges that can hinder the support EHRs can offer under these reimbursement models.

For starters, Goodrich and others note that the industry still struggles with getting data from one provider or institution to another. This lack of widespread interoperability often leaves primary care physicians trying to manage patients without all the relevant data needed to make the best decisions.

Some physicians will have more difficulty than others in overcoming this challenge, Rajput says. Physicians whose systems are five or more years old will likely need a major upgrade, if not a completely new system, Rajput says, because older systems are less likely to be compatible with the data exchanges and information-sharing networks that are emerging in many areas. 

Meanwhile, Beck says, physicians with new systems, systems recently upgraded by vendors to meet certification standards from the federal Office of the National Coordinator for Health Information Technology (ONC) or cloud-based EHRs that vendors (rather than the users) update automatically, need to activate all the features in their EHRs that support value-based care. Moreover, he advises physicians to ensure that they’ve integrated all those functions into their workflows.

“If I have decision support that pops up that reminds me the patient needs a colonoscopy, and I don’t act on it, then the tool doesn’t help me. So modifying the workflow is probably the most important thing to do [to support value-based care],” Beck says. 

Until there’s universal interoperability, physicians should take steps to ensure their EHR can electronically send and receive data from other doctors and institutions most likely to treat their patients, Beck adds. If that’s not technically possible, physicians might need to switch their existing EHR to the one used by the biggest player in their region or join the regional exchange, if one exists. 

As value-based care progresses, Beck says physicians themselves must work to get the most out of their software, using their EHRs to the fullest capabilities, if they want to succeed under this new reimbursement model. 

“Most EHR vendors have these tools, the question is: Have the tools been implemented in the practices?” Beck says. “The way I see it is it’s not the tools themselves that need development but the challenges of using the tools.”