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Succeeding in Value-Based Care

Raising the Bar: Adapting Legacy EHRs for High-Value Primary Care

This is part two of a series focused on the opportunity to dynamically transform the way EHRs support primary care physicians. For part one, go to “Measuring success based on PCP burnout: The next frontier for modern EHRs

Support for value-based payment in healthcare is gaining significant traction nationally, yet taking it from pipe dream to implementation is difficult, particularly in primary care settings. Primary care is the U.S. healthcare system’s best investment for positive health outcomes, but payment models have been slow to support the link between care and quality, undermining physicians’ ability to sustainably deliver the best patient care. Similarly, health technology has been slow to evolve to support the emerging needs of new care delivery models responding to the shifting payment landscape. 

Electronic health records (EHRs) are the technology backbones of modern practices, and they play a significant role in supporting the transition from fee-for-service (FFS) to alternative payment models that better support value-based care delivery. These alternative payment models (APMs) vary and often are deployed in combinations, but typically include performance-based incentives, shared savings programs, prospective or “capitated” payments, or membership models (direct primary care). These new payment mechanisms are designed to incentivize better patient outcomes at a lower total cost of care, but it isn’t enough to just correct the incentive structure. To achieve different results, the care delivery itself must be transformed. 

Historically, EHRs were designed to optimize billing, and not much was invested in optimizing the clinical experience. Along the way, the sanctity of the patient-provider relationship became secondary and the EHR became a distraction from the clinical experience, with excessive typing, mouse-clicking, and cognitive burden as clinicians struggled to make sense of the user interface. As a result, primary care physicians spend over one-third of their weeks on EHR documentation, paperwork, and other administrative work, distracting from the delivery of actual clinical care that measurably delivers better results. As we explored in this blog post, this balancing act has been a contributing factor in driving physician stress and burnout. 

Value-based care delivery within the framework of traditional EHR systems isn’t making physician lives—and patient focus—any easier. In fact, most traditional EHRs make the process even more difficult, requiring workarounds, disparate systems, additional documentation activities, and more manual and error-prone processes. This is in addition to processes that already existed in fee-for-service (FFS) models, since most practices undergo a slow migration from FFS to APMs, operating simultaneously in both business models for years. The resulting effect is even more administrative burden and stress and a world in which the transition from FFS to VBP seems insurmountable. 

While EHRs can’t fully resolve all of the contributors to physician stress, they can be effective in reducing administrative burden and facilitating certain processes, thereby increasing the time physicians spend connecting with patients and helping create a more sustainable environment in which physicians can provide high-quality care. It is time for EHR vendors to hold themselves accountable for expanding capabilities that support the growing innovation in primary care delivery models designed around producing better value in healthcare.

Don’t throw the baby out with the bathwater 

Billing and payment are still foundational for primary care practices to remain financially solvent and stable. Likewise, documentation of patient care and completion of patient-related tasks between office visits are vital, along with delivering timely access to care, preventive services, and longitudinal treatment (just consider the movement to ensure that there is legislative support for the inherent costs clinicians may incur when longitudinally treating complex chronic conditions). These are very basic components of providing high-quality care. These functions should remain a capability of modern EHRs.

Value-based payment arrangements incentivize clinical care designed around delivering better patient outcomes. This care model involves new activities and workflows primarily focused on improving collaboration and coordination of care – activities which are somewhat rare in legacy delivery models. A crop of point solutions has erupted to support these activities, but without careful integration into the native EHR workflow, they often end up forcing physicians to duplicate and fragment their work. Unfortunately, the clock is ticking: with value-based payment (VBP) interest dialing up, physicians are stuck being asked to deliver the highest-quality care possible, do more administrative work than feasible, and use legacy or parallel health technology that doesn’t support their workflow needs. Point of care is where the rubber meets the road: VBP solutions must also solve for the “last mile” experience of primary care physicians and their care teams.

Supporting VBP through better healthcare technology 

The promise of VBP is a revolutionized primary care experience that is centered around the patient, built on the physician-patient relationship, and is coordinated, collaborative, and proactive. It must enable key value-driven processes within the practice as well as the nuts and bolts of maximizing revenue in value-based contracts. This approach is not only enabled by technology but highly dependent upon it in order to be successful. Because Elation Health is mission-focused on supporting high-value primary care, we decided to survey our customers on their experiences related to their ability to deliver this kind of care using Elation’s EHR. 

Included in this groundbreaking survey were questions covering three domains of value-based success, specifically: impact on the patient, practice, and operations. To be clinically and financially successful in delivering high-value care, a practice must excel in all three areas.  EHRs can and should be the core operating system to facilitate this success, but all EHRs have strengths and weaknesses. 

When evaluating our own EHR here at Elation, we confirmed that Elation performs well at centering patients – aligning with our mission. When survey data were analyzed by payment model cohort, we found that for practices in value-based payment contracts specifically, Elation performs best at support for both in-person and virtual care from a single platform (a score of 7.7 out of 10 on a likert scale) and coordinating and tracking care longitudinally (7.6 out of 10 on a likert scale). Elation also scores high for impact on the practice – especially in the area of collaboration with internal team members (score of 8.5 out of 10 on a likert scale). 

Areas of weakness were identified as well, with Elation’s lowest performance in the category of getting maximally reimbursed (6.3 out of 10 on a likert scale). Notably, this survey was conducted prior to the launch of Elation’s new all-in-one billing solution, which is expected to address this specific weakness. 

What other EHRs and health technology leaders can take from these findings is that all three of these domains (impact on the patient, practice, and operations) must remain at the center of modern solutions, especially for value-based care and the payment models designed to support it. 

A Call to Action for Better Technology

This work can’t be done alone. While primary care physicians live in EHRs day in and day out, they are powerless to independently enact the changes they’d like to see in the technology they use. EHR vendors have the opportunity to improve healthcare in America by holding themselves accountable for driving down administrative burden and designing for success at the last mile in primary care: the frontline workflows tied to value-based payment success. EHR buyers, technology analysts, and evaluators (e.g. KLAS and Gartner) all can help accelerate this change by evaluating the success of EHRs based on their ability to drive down administrative and cognitive burden and fully support successful value-based payment models. At this new core: Protecting the time, resources, tasks, and integration it takes to deliver the highest quality primary care. 

The future success of primary care is tied directly to value-based care, and the American healthcare system depends on it. No longer can we ask primary care physicians and their teams to bear the burden of delivering the care, shouldering the additional administrative work, and risking their personal well-being and financial stability to do so. We urgently need to design technology that is purpose-built to facilitate success for the most important and powerful physicians within our healthcare system.

Sara J. Pastoor, MD, MHA is Elation's Senior Director of Primary Care Advancement and leader in primary care advocacy. Dr. Pastoor is a board certified and clinically active family medicine physician. Her experience as a primary care innovator spans a career in military medicine, academic medicine, private practice, and employer-sponsored delivery models. She received her MD from Rosalind Franklin University of Health Sciences and MHA from Trinity University.