A recent study of health care organizations showed that most are not prepared to deliver standardized longitudinal care across multiple provider systems. Shared care plans will be the centerpiece of coordinated care delivery, incentivized by the move from fee-for-service to value-based care. In 2015, Medicare unveiled its plan to transition to quality-based payments via the Merit-Based Incentive Payment System (MIPS), which will sunset and subsume earlier quality-encouraging programs, and move away from fee-for-service. The current programs — quality measures and reporting (PQRS), meaningful use (EHR incentive), and resource use (value modifier) — will all be rolled into MIPS by 2019.
Given this change in direction in how we pay for health care, it is important for institutions and individual clinical practitioners to have a way to share care plans with each other, and coordinate care much more seamlessly than has occurred historically. Yet, as the recent study shows, we are several years away from being able to do that. Why is this?
One reason is the way health care delivery is organized. An increasing proportion of health care is done within institutions, which, by virtue of their size, can hire the necessary ancillary staff to carry out much of the work of care coordination, quality measurement of the health of populations, and outreach to patients. Physicians are able to simply do the job of being a physician, and the system does the heavy lifting when it comes to all the care-coordination and quality-measure-driven outreach that value-based care implies. Small wonder that the majority of graduating medical students are looking at employment by institutions, rather than setting up their own private practices.
At the same time, though, much of health care delivery is still done in small practice settings, in 1 to 5 physician groups, or 6 to 10 physician groups. Referrals are made not to other members of the same institution, but to other independent practitioners in the community. In this more disaggregated setting, efforts to coordinate care and come up with a holistic, unified care plan for a given patient are much more problematic.
Limitations of technology infrastructure
In health care, the legacy of clinical data is in electronic health records (EHRs), which are institution-centric data silos that capture various segments of a given patient’s health story. The federal EHR incentive program (meaningful use) has encouraged the sharing of standardized data between institutions using different platforms — which is now occurring with varying degrees of success. Yet these efforts leave the data in institution-centered silos and merely share copies of information found in external systems. It does not break down the barriers.
Value-based care requires that health data transitions from its local-provider-centricity to a new model of universal patient-centered data, which can aggregate data from multiple sources — clinical EHRs from both physicians and hospitals, payer data, patient-entered data, and (increasingly) wearable-device data. We do not have this kind of platform in the mainstream, though such efforts are now emerging.
A universal patient record needs to be something that is outside any given provider’s EHR, but is viewable by everyone, as though the data were native to each silo. It eliminates the current dilemmas of needing updates from foreign sources via health data exchanges, of patient-matching issues when combining records from different places, and of data “standardization” implemented differently by different institutions.
How we can move to value-based health care delivery
Of course, technology alone is not the whole solution we need in order to create shared, coherent care plans. Developing them regularly and predictably will require that organizations do their work differently. And the problems will be particularly challenging for small, independent, community-based clinical practices.
A technology platform easily used by clinicians and care managers across institutional boundaries, that re-organizes health data into a patient-centered model (not an institution-centered model), will be required for this transition to be successful. Only when everyone taking care of the patient, as well as patients/consumers themselves, are all “on the same page” and seeing the same shared clinical information, will the vision of value-based care be achieved. Then a coordinated, holistic care plan can emerge that will make a difference in a person’s health.
It is not reasonable to expect that EHR vendors will be able to achieve this. Without exception, EHRs are built around institution-centered data. And no vendor, no matter how dominant it may be in the EHR market, will be the monopoly — despite the seductive allure of the promise: “If everyone used our product, the problem would be solved.” We need to move to a new paradigm.
As stated earlier, a platform by itself is not sufficient. We need to build it along with a network of clinical providers, health plans and consumers/patients, so that the result is meaningful. Though still early, these efforts are now emerging. The future: An interconnected network of providers, health plans and patients, organized around a universal patient-centered, longitudinal record, where care coordination, as envisioned in value-based care, becomes a reality.
Robert Rowley is co-founder and chief medical officer, Flow Health.
