As many healthcare industry insiders know, there is exciting energy coalescing around payment transformation, away from paying for volume of healthcare services (AKA “fee-for-service”) and towards incentivizing better health outcomes (AKA “value-based”). These payment innovations are happening in multiple sectors of the industry, perhaps most notably and impactfully in primary care where private investors, government programs, commercial insurers, and self-funded employers are all experimenting with alternative payment models (APMs). The goal of these efforts is to reign in wildly out of control total costs of care and get better value for the healthcare dollar. While this is likely good news from a long-term perspective, it is creating tremendous short-term turbulence in care delivery, where the changes in the incentive structures have created a seismic disruption in workflow related to a new set of rules and capability needs - for documentation, data, collaboration, patient engagement, analytics, and reporting.
There is ample evidence that high-quality primary care is a crucial component of a sustainable, affordable, high-functioning healthcare system. Yet the economics of healthcare, dominated by a transactional payment model known as fee-for-service, have weakened primary care and rendered it both less effective and less accessible. Complex, hypertrophic administrative infrastructures have been developed to support this payment model, in many cases costing more than the care delivery itself. Health technology has followed suit, intentionally designed around the documentation and billing needs of this model in order to translate individual clinical transactions into maximum reimbursement.
In many APMs, providers are paid incentives for their performance on certain quality measures, for identifying and reporting (to the payer) specific conditions which can be used to risk-stratify populations, and for providing specific services tied to better health outcomes. Whether or not these APMs are creating better value is a matter of ongoing study and discussion; meanwhile these models continue to evolve at a dizzying pace while primary care scrambles to keep up.
What we do know about payment transformation is that the health technology industry has some catching up to do. Performing (and reporting) the activities necessary to be clinically and financially successful in these APMs requires new tools - tools which, until only recently, have not existed in the healthcare industry. This has created frustration among primary care physicians (PCPs) who were already straining against monumental administrative burden and associated existential stress. Without the right tools integrated into the clinical workflow, PCPs have struggled to find a way to be successful in APMs, and this has stymied adoption of these new payment options even though they potentially hold the promise of better resourcing for primary care systems, higher income for primary care providers, and better outcomes for patients.
Legacy electronic health records (EHRs) which primary care practices and others have been using – in some cases for decades – have primarily been built to support success in the fee-for-service payment model. Clinicians struggle daily with these EHRs, complaining bitterly about them but enduring them as inescapable and trying to make the best of it. In a 2016 report, physicians surveyed about their experiences using ambulatory EHRs revealed abysmally low net promoter scores, ranging from 5% to negative 73%. It is rare to find a physician who says anything more positive about their EHR than, “it’s not the worst one I’ve used”.
Elation Health is the exception. The company’s founders set out to modernize the EHR experience for primary care clinicians, with a lofty goal of creating delight. Elation had its inception in the office of a solo family physician in 2010. In this clinical environment, Elation was designed around a physician’s relationship with his patients opposed to the coding and billing system. This “clinical-first” approach, combined with a deliberately intuitive design and a deep commitment to product development around the unique needs of primary care, has made Elation Health the most highly rated EHR in the U.S. today.
Although the health technology industry has recently rushed to offer “value-based” solutions aimed at enabling success in APMs, the majority of these solutions target a single problem set and are not integrated into the point-of-care workflow. The resulting fragmentation can feel to the primary care team like a Frankenstein experience, with various platforms, multiple login credentials, segregation of patient information, and duplication of documentation. A few EHR vendors have set out to evolve their native capabilities within a single platform, but this too proves problematic considering how many solutions are needed, the little we know about the best way to design these solutions, and the urgency in the primary care sector to solve these problems.
Elation’s unique approach has been to create an open architecture which invites seamless integration of a “best-in-breed” collection of solutions, all driven through the fundamental EHR workflow where primary care teams spend their time. The strategy is to design a product which offers a core set of native capabilities focused on the unique needs of high-value primary care, and let the user customize a digital ecosystem tailored to the particular needs of their care delivery program(s) without creating fragmentation or duplication of workflows.
In a recent study performed by the American Academy of Family Physicians Innovation Lab, Elation users told study researchers that using Elation’s platform dramatically decreased their experience of stress and burnout and increased their practice satisfaction. Plus, their satisfaction with tool integration increased from 4 out of 10 with their previous EHR and to 8.9 out of 10 with Elation.
But the proof is in the pudding. If the healthcare dollars are migrating towards value-based payment arrangements, can Elation’s strategy and user experience deliver success by design in these models? The answer is “yes”.
Consider, for example, a physician organization supporting over 800 independent physicians in the shift to value-based arrangements. In this case study, new quality program requirements increased physician administrative burden and added risk to the practice revenue and overall practice viability. The organization deployed a population health vendor in an effort to address these challenges, but this was not effective in engaging providers because it was segregated from their EHR and lack of data integrity was causing inaccurate reporting.
Elation seamlessly embedded compliance requirements within the natural clinical workflow and automated the coding based on documentation already being captured in the encounter notes. This reduced cognitive and administrative burden for the physicians and drove remarkable success in their value-based programs:
An increase in chronic condition assessment rate of 21%.
An improvement in post-hospitalization transitional care management services of 300%.
An increase in coding for body mass assessments (already being performed and documented in the encounter note) from 32% to 98%.
An increase in coding for blood pressure screenings in hypertensive and diabetic patients from 18% to 97%.
As a result, 96% of PCPs performed better or earned more incentives than the previous year, and 100% of them were eligible for the maximum performance-based incentive that year.
This is not a fluke. In another example, a physician organization with 250 PCPs serving an aging, urban population faced challenges with its Medicare Advantage provider network. They were under-performing on HEDIS and Care for Older Adults (COA) measures, and under-documenting chronic conditions using hierarchical condition codes (HCC). Using Elation, PCPs experienced:
An increased awareness of care gaps (HEDIS and COA) and HCC codes through real-time reminders delivered elegantly within the natural clinical workflow.
Automatic coding for services already being provided.
Efficient templates to help guide the workflow and documentation.
Alerts/reminders of previous and suspect chronic conditions to be assessed.
As a result, this physician organization realized:
A 200% improvement in care gaps closure within 1 year.
A 19% increase in HCC coding.
A recapture of $2,208 more per patient than PCPs in this same group using other EHR platforms.
In a third example, Elation worked with an independent physician association (IPA) responsible for a large Medicare Advantage population. Within this IPA, 58% of the patients saw a PCP using Elation, while the remaining 42% saw a PCP using either paper charts or another EHR. PCPs in this IPA who were using Elation had an HCC recapture rate eleven times higher than the PCPs not using Elation. This had a stunning impact on revenue, resulting in an increase of $1.62M per 1,000 patients.
Not only is Elation creating success by design for PCPs in value-based payment arrangements, but the Elation methodology outperforms EHR competitors in these payment models and Elation users love the product. It’s clear that Elation’s focus on primary care and the innovative approach of maintaining an open architecture ripe for integration is a winning strategy and a key enabler for primary care success in a value-based world.