Cur­rent gen­er­a­tion of EHRs im­pedes vol­ume-to-value trans­for­ma­tion

Modern Healthcare - - COMMENT - By Scott Wal­lace

As the last fed­eral elec­tronic health-record fund­ing washes ashore, the health­care in­dus­try braces for another big wave: the trans­for­ma­tion from vol­ume to value. The shift from vol­ume-based re­im­burse­ment means chang­ing how health­care or­ga­ni­za­tions get paid for care—and there­fore, how they think about it. Value is the im­prove­ment in out­comes for the money spent.

In a value par­a­digm, fi­nan­cial suc­cess re­quires that providers re­duce the need for care and find new ways to keep peo­ple healthy.

So far, so good: Align­ing the eco­nomics of health­care is some­thing ev­ery­one agrees on. Un­for­tu­nately, health­care or­ga­ni­za­tions have in­stalled a vast ar­ray of EHRs that are ham­per­ing that trans­for­ma­tion.

De­spite claims about im­prov­ing safety and ef­fi­ciency, EHRs are mostly de­signed for vol­ume-based re­im­burse­ment, en­sur­ing that in­for­ma­tion needed to bill for ap­point­ments and pro­ce­dures is col­lected. But they don’t fa­cil­i­tate care in­te­gra­tion or the com­mu­ni­ca­tion nec­es­sary to make care in­te­gra­tion a re­al­ity. A whop­ping 90% of sur­veyed nurses re­ported their EHR im­peded com­mu­ni­ca­tion be­tween nurses and pa­tients. Even RAND Corp., an early EHR booster, in 2013 backed away from its 2005 pre­dic­tion that EHRs will save health­care more than $80 bil­lion a year.

Adding to the mis­align­ment of prom­ise and re­al­ity, EHRs are rarely sen­si­tive to who shoul­ders the dat­a­col­lec­tion bur­den. A re­cent study by Drs. David Him­mel­stein and Stephanie Wool­han­dler showed that doc­tors with EHRs spend more time on ad­min­is­tra­tive tasks than those with only pa­per records.

EHRs also don’t pro­vide suf­fi­ciently cus­tom­ized in­for­ma­tion to help clin­i­cians meet the needs of in­di­vid­ual pa­tients. Needs dif­fer sig­nif­i­cantly among pa­tients: com­pare those of a child with can­cer, an el­derly per­son with con­ges­tive heart fail­ure and a healthy mid­dle-aged per­son seek­ing to pre­serve good health. Be­cause EHRs don’t support care at this level, and in­stead place greater fo­cus on high-level records and billing in­for­ma­tion, they make care de­liv­ery harder and in­hibit the tran­si­tion to value-based care de­liv­ery.

The gusher of fed­eral funds achieved its stated goal of spurring adop­tion, but few health­care or­ga­ni­za­tions thought about the im­pact of an EHR on the work­flow of clin­i­cians. The cost of the sys­tems had to be paid up­front, with in­cen­tive dol­lars flow­ing in later years, and many providers lacked the re­sources to thought­fully de­sign or ef­fec­tively man­age the sys­tem’s launches. Cash-strapped, over­whelmed or­ga­ni­za­tions couldn’t re­struc­ture care de­liv­ery to stream­line pro­cesses and make use of some of the EHRs’ ca­pa­bil­i­ties, and clin­i­cian dis­con­tent grew.

Mov­ing for­ward, ser­vices must be struc­tured around pa­tients with sim­i­lar needs. Then EHRs can pro­vide decision support along care paths and records of pa­tient pref­er­ences while im­prov­ing team com­mu­ni­ca­tion and en­abling out­come mea­sure col­lec­tion.

EHRs should be easy to use ef­fi­ciently. On­line re­tailer Ama­zon mon­i­tors the num­ber of key­strokes its cus­tomers take in the course of plac­ing an or­der. Like­wise, EHRs of the fu­ture have to rec­og­nize that ev­ery click and key­stroke mat­ters to busy clin­i­cians. EHRs must pro­vide the in­for­ma­tion clin­i­cians need—and only the in­for­ma­tion that is needed. Re­minders and alerts must be more cus­tom­ized to each pa­tient’s cir­cum­stances, rather than trig­ger­ing a cas­cade of use­less menus that re­quire rote re­ac­tions.

The Cleve­land Clinic has adapted its EHR to support clin­i­cians within their ex­ist­ing work pat­terns. One in­no­va­tion al­lows clin­i­cians to ac­cess in­for­ma­tion about mul­ti­ple pa­tients with­out hav­ing to log in and out of mul­ti­ple records. De­scribed by CIO Dr. Martin Har­ris as “elec­tronic round­ing,” the in­for­ma­tion from the EHR flows the way clinic doc­tors at­tend to hos­pi­tal­ized pa­tients.

The EHR that Bos­ton-based Iora Health de­vel­oped for its clin­i­cal teams is so in­tu­itive that new users learn to use it on their own in less than an hour. Au­to­mated reg­istry func­tions help Iora mon­i­tor pa­tients’ health, and search func­tions al­low clin­i­cians to eas­ily find rel­e­vant in­for­ma­tion.

KLAS, a health­care tech­nol­ogy re­search firm, this past sum­mer re­ported that more than a quar­ter of clin­i­cians want to re­place their EHR. To support the vol­ume-to-value trans­for­ma­tion, the pri­mary fo­cus of the next-gen­er­a­tion EHRs has to be mak­ing it eas­ier for in­di­vid­ual care­givers to im­prove pa­tients’ health. In a value world, EHRs have to be tools that help, rather than im­pede, clin­i­cians.

Scott Wal­lace is a vis­it­ing pro­fes­sor at Dart­mouth’s Geisel School of Medicine and was the first pres­i­dent and CEO of the for­mer Na­tional Al­liance for Health In­for­ma­tion Tech­nol­ogy.

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