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Practices must embark on a journey that goes beyond new technology.
Dr. Saunders is CEO of Integra Connect, West Palm Beach FL provider of technologies and services for value-based specialty care. Integra Connect partners with large groups in the U.S. focused on oncology and urology, as well as with other key health care constituents.
With 2018 behind us, it is a natural time to reflect on the major developments that took place in health care in general and urology specifically. For many, it will be remembered as the year that value-based care became a reality. Just over a year ago, Urology Times reported that only one-fourth of urologists understood the choices available to them as part of the Merit-based Incentive Payment System (MIPS) and alternative payment model (APM) programs created by CMS (Dec. 2017, page 1).
Fortunately, some of that confusion has since dissipated. With only a couple of urology practices participating in an APM-the Oncology Care Model-and no urology-specific candidates yet approved, most urologists are experiencing value-based care through MIPS.
With the first MIPS results released last November, urologists began to better understand the clinical, financial, and operational inputs that would positively or negatively affect their MIPS performance. One area of focus: the suitability of the technology tools and infrastructure on which their offices depend. Around the same time, we sat down with the leadership of 25 prominent urology practices nationwide to talk about the tools they were looking for in a value-based world.
A new job for urology EHRs
During the fee-for-service era, the electronic health record established itself as the central technology of many urology practices, and with good reason. It was designed specifically to document patient encounters in the office setting, with an eye on the billing and collections workflow to follow. However, as MIPS has evolved-specifically, with the introduction of cost as 10% of the overall MIPS score for performance year 2018-it has become increasingly important for urologists to manage their patients more holistically, across all care settings and comorbidities.
The urology practices in our group said they need access at the point of care to information and insights that draw from an array of clinical and financial inputs, across entire care teams. Legacy EHRs, with their notoriously closed architectures and difficult data access, were simply not built for these value-based requirements.
As a result, more than half of the practices in our group said that in the next year they either will change their EHR (19%) or are actively looking to change it (35%). Interestingly, nearly all of those wanting a new EHR solution espoused the need for new requirements, driven by value-based considerations. They specifically want to take the opportunity of an EHR replacement to help them positively change their clinical operations and reduce treatment variability. Fifty percent say they want to make major changes, while another 42% seek modest changes.
When asked what kinds of value-based capabilities will be important, they pointed to: integrated care pathways, including tracking of deviations (54%); a historic patient timeline for an at-a-glance, longitudinal overview (43%); and real-time alerts on gaps in care/actions to complete for patients (39%). This vision for a value-based EHR goes beyond the scope of what existing legacy solutions provide.
Next: Data and analytics at the centerData and analytics at the center
If the EHR was a technology linchpin for fee-for-service billing models, it is transitioning to become just one component-albeit a critical one-sitting atop a new data foundation needed to power value-based care success. The ability to support cross-functional, team-based care across settings and venues, during and in between office visits, with access to rich clinical and financial patient data, requires the integration and harmonization of data from disparate sources that have not traditionally talked to one another. This may take the form of a practice-level health information exchange that can aggregate, integrate, and exchange population-based information, including medical claims, clinical, lab, prescriptions, and sociodemographic and bio-genomic data.
Value-based care also necessitates a redoubled focus on the quality and consistency of all data. We recently studied the data requirements for a selection of urology-specific MIPS measures and found that while most inputs resided in the EHR, more than two-thirds were unstructured-for example, captured in narrative notes with an elevated risk of errors, duplication, or even omission. Many practices found that they needed to manually abstract and curate charts in order to submit measures properly.
Practices are looking for this investment in new technology capabilities and protocols to pay off in the form of a new generation of analytics that can drive both insights and action for MIPS and future APMs. Urology groups told us their wish list includes new clinical, financial, and population health analytics:
While the emerging requirements of value-based care will necessitate changes to urology practice infrastructure and tools, it is important to recognize that a larger transformation will also be essential as well. In parallel, practices must expect to embark on a journey to adopt a broader, more holistic patient view; a new array of financial and clinical considerations; and a cultural commitment as they assume risk. Value-based incentives have the ability to determine the future sustainability of most practices, with the inevitable addition of APMs-either from CMS or commercial payers-as a further accelerant.
The combination of practice transformation with suitable enabling technologies will be an important determinant in which fork in the road urologists ultimately follow.