Skip links

Improving the Role of EHRs in Population Health Management

By on

The Department of Health and Human Services has spent half a dozen years and billions of dollars trying to convince healthcare providers that the electronic health record is a valuable tool for improving the quality and coordination of care across the healthcare continuum.  While the goals of the Triple Aim may still remain squarely in the sights of the healthcare industry, CMS and the ONC have been dodging sharp words from unhappy providers who believe their technology isn’t ready to meet the expectations foisted upon them.

When looking at the number of providers who have adopted EHRs over the past six years, meaningful use appears to be an incomparable success.  After more than $30 billion in incentive payments, more than 90 percent of hospitals and 127,000 physicians are now using an electronic system – yet widespread complaints about lost productivity, unstable finances, frustrating interfaces, and lackluster communication have marred the program since the very beginning.


Congressional lawmakers have periodically questioned the progress and impact of the EHR Incentive Programs and related initiatives to improve health data interoperability and foster a big data-driven environment conducive to population health management and value-based reimbursement, and the answers they have received haven’t always been satisfactory.

This week, a hearing entitled “Achieving the Promise of Health IT: What Can Providers and HHS Do to Improve the EHR User Experience” raised the same queries yet again.

How is poor EHR usability preventing providers from engaging in meaningful clinical analytics and health information exchange?  What role should electronic health records play in the push for more robust population health management, which has the potential to reduce costs, improve the quality of care, and better tackle the growing problem of managing chronic disease?  How can the EHR Incentive Programs drive the necessary technical and administrative improvements without overburdening providers?

Three healthcare experts sat in front of the US Senate Committee on Health, Education, Labor, and Pensions (HELP) to try to answer these questions.  Their responses followed several key themes, none of which are particularly new to the continually struggling industry: in order to make sure that EHRs are a help instead of a hindrance to healthcare reform efforts, health IT infrastructure must be built on data standards, encourage health information exchange and clinical analytics, provide an intuitive and productive experience for users, and keep the needs of the patient at the center of care.

The healthcare system must start by ensuring that information entered into the EHR exhibits a high level of data integrity and adheres to accepted data standards that can be read and acknowledged by EHRs across the care continuum.

“One of the important value propositions for providers in the digital age is the free flow of information,” said Dr. Vindell Washington, President of Franciscan Medical Group and CIO of Franciscan Missionaries of Our Lady Health System in Louisiana.  “Having key clinical data from all points of care has been a challenge for decades and the speed of future clinical improvements will depend on our ability to aggregate data from disparate clinical systems.”

But information is often coded into formats, such as the Continuity of Care Document (CCD), that aren’t always compatible across different EHRs.  “A vendor may produce a certified CCD, but this does not mean that another vendor can translate it into an understandable format,” Washington points out. “A more specific standard would help in this regard.”

Furthermore, the use of multiple coding languages and terminologies is fragmenting data instead of standardizing it, he said.  “Some of the problems rest in the fact that there are many areas of medicine that don’t use truly standard terminology; therefore, setting a technical standard will not fix all issues in this space.”

“For example, in laboratory, Logical Observation Identifiers Names and Codes (LOINC) give a standard format, but variance still exists in whether all laboratory values in all clinical systems maps to this format or any single format. The lack of full standardization leaves providers to input discrete data into their system, without getting the benefit of cross communication between systems.”

Poor standardization makes it difficult to engage in the clinical analytics and patient risk stratification that lies at the core of effective population health management, added Meryl Moss, MPA, EMHL, Chief Operation Officer at Rhode Island’s Coastal Medical, Inc.

“One of Coastal’s biggest challenges has been in the area of data analytics,” she said. “We are fortunate that we receive claims files from CMS, United, Tufts, and Blue Cross. However, extensive work needs to be done by our analysts to process those files in a way that helps us to understand how we can intervene with patients to impact the quality and cost of care. This work is currently very costly and inefficient.”

“Smaller physician groups probably cannot afford to make the investment needed to do this work, and in which case the cost of investing in analytics becomes a barrier to their entry into population health management and new payment models.”

“We are moving to population health management, and this work is virtually impossible without the right information,” she continued. In order to overcome these challenges, Moss suggests that future editions of the Certified EHR Technology (CEHRT) criteria include a heightened focus on analytics capabilities to ensure that all providers adopting EHR technology certified for meaningful use will have access to a certain level of population health management capabilities without having to purchase costly add-ons or additional vendor packages.

But EHR vendors cannot increase data analytics capabilities without taking on the massive and unwieldy challenge of health data interoperability first, Timothy A. Pletcher, DHA, Executive Director of Michigan Health Information Network and an adjunct faculty member of the Department of Learning Health Sciences at the University of Michigan Medical School, said to the Committee.

“If we are to achieve the vision of a Learning Health System we need to prepare for ultra-large scale data sharing,” he stated.  “While there has been considerable success in motivating hospitals and providers to adopt individual EHRs, connectivity between those disparate EHR systems and networks, and standards for how data is captured, stored and communicated, involves complex and burdensome problems that cause considerable frustration in the lives of providers and their patients,” he said.

The healthcare industry cannot manage the overwhelming complexity of developing millions of point-to-point connections between individual EHRs without the help of centralized organizations, like state-level health information exchanges, that can act as brokers between providers across communities.

In one use case for HIE, Pletcher says, targeted financial incentives for the use of admission, discharge, and transfer (ADT) data “have resulted, in less than two years, in 93% of all admissions statewide being made available to help providers coordinate the care of patients to reduce unnecessary readmissions or Emergency Department visits. Using Michigan’s Statewide ADT Use Case, recently one clinic saw their ability to support transition of care management rise from 3 to 5 patients per month, to 40 patients per month, a tenfold increase in care coordination.”

The key to this success – and continued efforts to improve the quality and integrity of the data being transmitted – are the financial incentives from payers, which encourage continued participation and ongoing improvement in clinical documentation accuracy and completeness.  Cooperation from the payer side is key to ensuring that value-based reimbursement aligns appropriately with the industry’s shift towards data-driven population health management.

“It is my observation over the years that providers routinely share as much information with those who pay for or regulate care as they do with other providers,” Pletcher said. “And yet the health plan or payer community, especially the commercial health plans, have been remarkably absent from the meaningful use dialogue and the associated data sharing.”

“Providers have been encouraged to send a certain percentage of their transitions of care to other providers using specific technology like Direct Secure Messaging (DSM), yet all of their interactions with health plans are done either by a payer-specific portal that requires the provider to remember another login ID and password or to use a fax machine,” he added. “A major opportunity exists to have the health plans begin to adopt the same data sharing approaches as providers.”

Payers may not have the most sophisticated data sharing connections with providers, but they have been largely successful when it comes to signing up providers for accountable care organizations (ACOs) that put population health management at the center of their mission.

Yet ACOs and other value-based reform efforts cannot flourish if providers are still stuck using confusing, frustrating interfaces that suck hours of time out of their day, leaving just a few precious minutes left over for the central business of building patient relationships and delivering quality care.

EHR usability must be addressed before providers can take on the challenge of complicated workflows related to data analytics and population health, Washington says, and most health IT options aren’t allowing providers to work to their highest level.

“The current information workflow and documentation requirements are largely based on paper documentation efforts,” he argued.  “Checking boxes to show that data was reviewed, or that tests were performed, or attestations of agreement with documentation performed by others on the healthcare team place unnecessary burdens on providers and do not substantially improve care.  It also lessens the value of providers practicing at the top of license.”

As the industry switches from volume to value, the importance of documentation as a check and balance should lessen and providers should be rewarded more for expected outcomes,” he continued.  “Documentation should consist of gathering the necessary elements for continuity of care – as a reminder to providers of the care provided on a certain date and time.  Documentation in the new workflow should be a product of care delivery.  EHRs are becoming capable of constructing care documents as a product of information gathering, but this effort will be stymied by burdensome documentation requirements.”

Simplified documentation will only be possible if private payers and the EHR Incentive Programs – or any health IT initiatives that come after – better streamline their data reporting requirements by eliminating duplicate or conflicting clinical quality metrics, said Moss.

“If CMS and commercial payers were to establish an agreed upon ‘core’ group of quality measures, and if electronic health vendors were driven to support that ‘core’ through certification standards, this could greatly improve the efficiency of quality measurement, quality reporting, and quality improvement across our industry,” she said. “The physician community could be certain that whatever record that they purchased would have the basic functionality to manage the core measures that should be used by insurers, the government and accrediting bodies.”

“We would recommend that incentive programs continue to reward EHR adoption, interoperability, improved patient access, and improvement of performance on quality measures,” Moss concluded. “This is still new work for many in our industry, and we are learning how to better care for populations of patients every day. These programs help us to focus on what is most important, and provide revenue for infrastructure support that is in short supply in many physician groups.”

Article Source:

Leave a comment