EMR Dreams of Value-Based Care
What do PCPs need from EMRs to enable value-based care?
Here’s the wish-list from a non-techie family doc.
Electronic medical records (EMRs) are one of the most influential inventions in the delivery of healthcare. They not only serve as a robust repository of medical information but streamline integration and information-sharing across space and time. They serve as the backdrop for clinical workflows, the interface for healthcare interactions, a means by which we are paid and regulated, and oft-bemoaned by clinicians and patients alike. We got our first computer when I was in elementary school, and I still remember paper charts from my trainee days. I’m quite thankful for the transition to digital even though I would not proclaim myself a techie. As momentum grows towards value-based care (VBC) systems, we must look at adapting this tool to better meet the needs of organizations, physicians and patients.
In VBC, governments, health systems, and insurance companies work to manage their patient populations with whom they are interacting and for whom they have accountability. Currently available applications within or on top of EMRs pull data from this vast repository. Once analyzed, population-level, macro-data may be shared with leaders and physicians who then must use this data to implement new programs or initiatives at the micro-level of the patient. As a practicing physician, the information can feel distant and disconnected from everyday moments in patient care. Although there is certainly a role for system-level data, primary care teams also need panel-management data and capabilities within the EMR for use at the level of the physician-patient interaction.
Sometimes I think it is hard for non-clinicians to understand the challenges for the primary care physician in the task of population management, so I’ll offer an analogy. My father and one of my sisters work as pastors. As we’ve swapped stories over the years, I’ve found the parallels between the role of pastor and primary care doctor uncanny. Pastors serve individual parishioners and are charged to think about the segmental needs of those in the “flock”, and not just on Sundays. They care for the elderly, the children, the spiritually mature, the occasional attendee, those who are not yet through the church door and everyone in between. Doctors who provide longitudinal care also have the immense challenge of both caring for the person in the exam room in the moment, and also being responsible for our panels between office visits. We see those who are highly engaged in their care and those on the periphery. Physicians can approach their role in two ways. The most expedient and traditional method has been to care for patient’s needs as they present. It is primarily a reactive mode. Most working in traditional practices have little time to proactively manage the healthcare needs of their panel outside of an office visit. However, it is this proactive approach that is best suited for value-based care, where outcomes are targeted both at the individual and segmental level.
The EMR capabilities for proactive management of patient segments is currently limited. Previously, patients with certain conditions were added to a paper or digital spreadsheet for tracking and recalls. Some EMRs now provide a step-up from these manually kept registries, allowing physicians to run parallel patient lists from their panel: the due-for-colonoscopy list, the uncontrolled-diabetes list, and the due-for-mammography list but not who’s actually on all three lists. Most of these dashboards are built around ‘services due’ rather than shared health conditions and provide little nuance. When outreach is performed, for example, for patients due for a colonoscopy, the outreach staff are blind to the numerous and simultaneous other (and perhaps more pressing) needs of the patient. In this example, a patient with multiple hospitalizations for a COPD exacerbation in recent months is not likely to be a good candidate to have a screening colonoscopy, but they are called to have one nonetheless.
Alternatively, when patients reach “inward” by submitting an email or a phone call, they come directly to our attention for that specific need. Physicians receive a message in their inbox, serving as notifications and reminders for concerns, ER visits, and completed consults or tests. It is a reactive type of functioning, and it is all-consuming. Only when we are really worried about a patient or see that a patient was recently hospitalized might we assign a reminder for a nurse to call them to see how they are doing. But what happens then to those who are not top of mind? No news is good news. Or is it? Patients easily fall off the radar if they are not reaching in, resulting in neglected opportunities to prevent the crisis in those who are at risk.
When we consider interventions to change the outcomes of populations, physicians need EMRs to provide visibility of patients as individuals and as members of various segments with shared health needs. A value-based care mindset looks also for ways to manage the panel from an outside-in perspective. Primary care panels tend to have the widest variety of segments. The physician needs to simultaneously “see” what is happening with their panel of one to two thousand people in real time and be able to ‘zoom in’ on the changes happening in certain segments. I recently read an article describing how to segment a population at the government level, and I believe this could also be applied to EMR design. Dashboards for physicians which integrate dynamic information (diagnoses, hospitalizations, ER visits, test results) and segment patients by risk category and multimorbidity might allow physicians to follow patients in between office visits more easily at a glance, and assign resources to patients more appropriately. Patients who become sicker, relapse, or become homeless move to the higher risk list for more intensive follow-up while healthy or stabilized patients might be better served with less frequent touches. Such dashboards might also help with balancing the resources needed for that panel, such as staffing assignments and scheduling templates.
EMRs built for VBC would also layout individual patient charts differently. Change over periods of time and over multiple visits in current EMRs is difficult and time-consuming to mine. VBC is defined by a change in health outcomes for the individual, and EMRs could do better at tracking this change. Here are some specific examples how EMRs could change to be more value-centric:
New patients charts. Intakes would include areas to document health goals, setting up the patient’s risk profile, and detailing information about their chronic diseases. Some of this already occurs at new patient visits, but gathering information from patients as they transition into a new health system is often quite an undertaking and laborious. Data input may be delayed by receipt of records, or once records are received, one is overwhelmed to wade through an abundance of data for what is relevant to the current situation. Artificial intelligence (AI) may be able to help by providing summaries of patient records and charts for ease of assimilation to a new system.
Physical exam documentation. Search functions are cumbersome, and it’s difficult to click through individual notes to find how someone’s exam has changed over time (e.g. is that murmur new? Did the nevus change size?). Some physicians have the practice to ‘carry forward’ data from previous notes, but this easily leads to excessively long and sometimes inaccurate documentation. A VBC-EMR might show a singular map of the body updated with a time-stamps on specific body parts when the exam is performed. Instead of documenting the physical exam in the note, relevant updates would be made to the central body-map. No need to write again about the amputated finger the patient has had for decades or wonder if anyone has noted the patient’s anisocoria. Imaging could also be mapped to a body diagram in addition to a date-oriented and searchable list.
Disease documentation. Some EMRs collate diseases by body system on the problem list, but many diseases affect multiple body systems and change over time. Hard-to-diagnose or complex conditions might be better elucidated using visual timelines of symptoms to be able to ‘put the pieces together.’ Instead of a problem list, a visual problem or journey map might better capture what is happening in the patient over time. Take a patient with poorly controlled diabetes who starts to manifest neuropathy in addition to their retinopathy and cardiovascular disease. Instead of adding a nearly redundant code of “diabetes with neuropathy” onto the problem list next to five other diabetes codes, the problem map might show a body map of diabetes with manifestations and various affected organs highlighted.
Summarize previous treatment trials. Though closely related to the previous bullet with chronic disease management, physicians need to be able to quickly recap all previous treatments when current treatments are failing or need to change. AI also could be helpful here, as it currently takes a manual search of the EMR (unless in the rare care that the PCP has been diligent in documenting previous medication trials on a detailed problem list). Many times a patient states that they tried this or that medication, but they don’t know the names or when. Improving value means reducing waste, and repeating treatments that aren’t effective tends to be frustrating at best and unsafe at worst.
Referrals. Consult notes might not be fully integrated into the EMR of the PCP. AI could help by reading a scanned document, summarizing the consult recommendations, and easing the updating of the new information into the PCP’s EMR.
Proactive management of treatment plans. EMRs that automate follow-up screening could shrink the negative impact when patients have trouble with a plan of care. For example, a newly prescribed medicine triggers an automated text message in three days to ask whether the patient received their medication and is having any concerns. Perhaps the medication wasn’t covered, and they left the pharmacy without their prescription but didn’t contact the PCP’s office. A simple reply of “Y” by the patient sends a message to the team to contact the patient for trouble-shooting to find an alternative.
Measuring outcomes that matter. Tracking outcomes that matter is vital to VBC. Some EMRs have a fairly good repository of PROMs but there are many steps to access and track these over time. Expanded PROM options for common conditions and prompts to use them at the time of diagnosis and at pre-defined intervals could allow for easier tracking of health outcomes. If physicians treat a disease, but don’t help achieve the outcomes that matter, value decreases.
Tracking costs of care. This is certainly a controversial point. Physicians can feel squeamish about making decisions using cost, even though patients often want to know this information (and they have a right to it). Will the patient forgo care if they know what it costs? Will there be rationing of care? I wonder if there would be less worry if outcomes and cost were displayed side-by-side at least at a panel-level.
Ask patients what they need! What else do patients want from their health record? Hopefully EMR companies are asking. AI might be able to provide summaries of health information in lay-terms, provide more access to more education about their conditions, and give patients the ability to track their own progress towards outcomes that matter to them.
Physicians need EMRs to adapt to facilitate the movement towards VBC and outcomes that matter to patients. Of course, there are many other transformations that need to take place for physicians to use a such features. Physicians need time and a new set of expectations and operations for effective panel management. To have time and a change of mindset, they also need to be paid in a manner that values health outcomes, freeing them to serve patients and their panels in a way that makes the most sense. Current EMRs lend data toward the denominator, that is, the finance part of the value equation with a focus on charge capture and billing. Reorienting the EMR around proactive care and the health outcomes of the patient, i.e. the numerator in the value-equation, will enable clinicians to better visualize and manage patient care from the individual and panel level. Some of my wish list items may be far and away, but if adapted for the VBC strategy, EMRs have tremendous potential to enable greater value for all stakeholders.
