Why aren’t EHRs delivering on Quality, Value, Return on Investment, Patient Outcomes…?
An important buzzword in healthcare today is ‘Value’.
The federal government and third-party payers are now demanding the transition from fee-for-service to value-based fees. Whereas fee-for-service is very well understood, the value of a healthcare visit is much harder to define, let alone put a dollar fee on that value.
With fee-for-service, the patient walks in, gets time with the physician (the physician performs a service), then the patient or insurance company pays for that service. The most effective way to increase practice revenue is to increase the quantity or number of visits.
Sure, one could increase revenue a bit by optimizing billing and collection rates (efficient revenue cycle management), by holding employee costs down (appropriate physician to employee ratios) but, relatively speaking, the independent physician makes more money by seeing more patients.
The ideal is improving the quantity of patients that can be helped, while minimizing any effects on the quality of care, and striving for the perfect balance of quantity and quality. Some physicians balance this well, others do not.
What exactly is value-based medicine? How is it measured? How is it reimbursed?
The platform for measuring value was envisioned as the electronic health record (EHR). With clinical information stored in a structured database, one could quickly and efficiently measure, and then report on, various clinical parameters.
The idea was that the electronic health record would, in fact, improve office efficiency, improve patient satisfaction, improve clinical treatment outcomes, improve practice revenue, improve the exchange of medical information between physicians, decrease medical errors, decrease medication-allergy adverse reactions, decrease prescribing errors, and profoundly affect the overall quality of healthcare in America. That was the idea and it was reasonable.
The government acted upon this philosophy by issuing programs such as the EHR incentive program in order to increase the EHR adoption rate (by paying physicians to purchase and use a certified EHR). And the Meaningful Use (MU) program was developed in order to measure the quality of the practice and/or individual physician.
In the next several years, physicians will be incentivized based on adhering to, and reporting on, predefined Meaningful Use quality measures. However, physicians will also be financially penalized for not reporting on such measures.
The problem with payment-for-value is that the majority of well-designed studies, looking at the impact of current EHRs, find that there have been no significant benefits in a number of areas. When looking at quality, value, return on investment, population health, or therapeutic patient outcomes, most studies have concluded there has not been an overall improvement in quality patient care or business practice efficiencies.
In fact, most physicians do not believe the EHR has had any impact on their delivery of quality medicine. Their patients do not appear healthier due to an EHR. The reasons for this are many, but most physicians blame poor EHR design, non-existent workflow, rudimentary clinical decision support, and poor usability & functionality. In studies, most patients like the idea of an electronic medical record but do not feel the EHR has truly, positively affected their health, except in perhaps lower pharmacy wait times through ePrescribing.
The mechanism by which to improve healthcare, and measure the quality of a practice or physician is, in reality, through the electronic health record. However, there are still a number of hurdles to overcome.
First, ease of use is paramount. But this must still facilitate and ensure that the all-important clinical information is captured in a structured data format. The data must be captured in an open-architecture, granularly designed database for easy querying of the appropriate clinical data.
Then, secondarily, the importance of workflow cannot be stressed enough. The appropriate information, delivered at the appropriate time (the point-of-care) in the physician’s therapeutic decision-making process, can only be effective through an integrated workflow engine. It is not good enough if the clinical decision support software is simply a stand-alone application which then distracts the physician and moves them away from the EHR.
Lastly, as the third step, the information provided to the physician at the point-of-care must be in the form of real-time outcome studies of their own therapeutic prescribing behaviors. If physicians see the outcomes for their own choices, they are far more likely to change their own treatment behaviors towards value and quality choices. That’s when the real quality improvements will finally be realized through the EHR.
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