At HIMSS this year in Las Vegas I looked at the nature of the EHR and if we have the current computing and data infrastructure to enable better value based care. Our data capabilities are failing to allow providers to align reimbursement with great care delivery.
Under the premise of “what gets watched gets done”, we understand that improving care delivery will require us to align incentives with desired outcomes. The challenge is that, among the many ills plaguing our version of the truth mined from data found in electronic health records systems, reimbursement data presents the core issue for informatics departments across the country. To resolve this issue, we need documentation to reflect the care we are delivering, and we need care delivery to center around patient care. Health information management should be heavily involved in data capture. To truly improve care, we need better tools to measure it, and healthcare data is expanding to answer difficult questions about care delivery and cost.
Our first challenge is stemming the proliferation of extraneous documentation, and healthcare is still addressing this issue. What used to be written on a 3-by-5 index card (and sometimes via illegible doctor’s notes) is now a single point in a huge electronic record that is, surprisingly, not portable. Central to our issues around the cost of care, we have also seen that quantity is valued more than quality in care delivery.
Duplicated testing or unnecessary procedures are grimly accepted as standard practice within the business of medicine. Meaningless and siloed care delivery only helps this issue proliferate across the health of a population. To resolve these issues, our workflow and records need to capture the outcomes we are trying to obtain and must be customized for the incentives of every party.
Incentives for providers and hospital administrators should center around value: delivering the best outcomes, rather than doing more tests. Carefully mapping the processes of healthcare delivery and looking at the resource costs at the medical condition level, from the personnel costs of everyone involved to perform a medical procedure to the cost of the medical device itself, moves organizations closer to understanding total actual costs of care. Maximizing value in healthcare–higher quality care at lower costs–involves a closer look and better understanding of costs at the medical condition level. Value and incentives alignment should provide the framework for health records infrastructure.
When you walk into Starbucks, your app will tell you what song is playing and offer options to get extra points based on what you usually order. Starbucks understands their value to the customer and the cost of their products to serve them. From the type of bean, to the seasonal paper cup, to the amount of time it takes to make the perfect pumpkin spice latte, Starbucks develops products with their audience in mind–and they know both how much this production costs and how much the user is willing to pay. The cost of each experience starts well before the purchase of the beverage. For Starbucks, they know their role is more than how many lattes they sell; it is to deliver a holistic experience; delight the customer each time.
Healthcare has much to learn about careful cost analysis from the food and beverage retail industry, including how to use personalized medicine to deliver the best care. Value-Based Healthcare reporting will help the healthcare industry as a whole move beyond the catch-up game we currently play and be proactive in promoting health with a precise knowledge of individual needs and cost of care. The investment into quantifying healthcare delivery very precisely and defining personal treatment will have massive investments in the coming years and deliver better care at a lowered cost. Do current healthcare information systems and analytics have the capacity to record this type of cost analysis?
“Doctors want to deliver the best outcomes for their patients. They’re highly trained professionals. Value Based Healthcare allows you to implement a framework so every member of the care team operates at the top of his or her license.”
-Mahek Shah, MD of Harvard Business School.
These outcomes should be based on the population a given hospital serves, the group of people being treated, or at the medical condition level. Measures of good outcomes are dynamic and personalized to a population. One of the difficulties in healthcare is that while providers are working hard for the patient, healthcare systems are also working to make a profit.
It is possible to do well while doing good, but these two goals are seemingly in conflict within the billion dollar healthcare field. Providing as many services as possible in a fee-for-service-based system can obfuscate the goal of providing great healthcare. Many patients have seen multiple tests and unnecessary procedures that seem to be aligned with the incentive of getting more codes recorded for billing as opposed to better health outcomes for the patients.
The work of Value Based Time Data Activity Based Costing can improve personalized delivery for delivery in underserved populations as well as for affluent populations. The World Health Organization (WHO) published the work of improving care delivery in Haiti. This picture of the care delivery team is population-specific. A young person after an accident will have different standards for what constitutes “right care right time right place” than a veteran with PTSD. Veterans might need different coverage than members of the general public, so value based care for a specific group of veterans might incorporate more mental health and behavioral health treatment than value based care serving the frail elderly, which could incorporate more palliative care and social (SDoH) care. Measuring costs with TDABC for that specific population would include not just the cost of specialists specific to each segment of the population, but of the entire team (social worker, nursing, nutritionist, psychologists) that is needed to deliver the right care, achieve the best outcomes, and meet the needs of the patient segment.
Healthcare systems are bombing providers and decision makers with information and trying to ferret out what that information really means. Where is it meaningful? Actionable? Process improvement teams for healthcare should look carefully at data with a solid strategy. This can start with cost analysis specific to given target populations. Frequently, the total cost of care delivery is not well understood, from the time spent at the clinic to prescribe a hip replacement to the time in the OR, to recovery time; capturing a better view includes accounting for every stage of care. Surgeons with better outcomes also have a lower total long-term cost of care, which impacts long-term expenses involved when viewing it through the lens of an entire care cycle. If you are a great surgeon–meaning your outcomes are better than others–you should get paid for it. The best care should be facilitated and compensated, rather than the greatest number of billing codes recorded. Capturing information about outcomes and care across multiple delivery areas means data must be more usable and more fluid than before.
Healthcare informatics systems should streamline the processes that are necessary to patient care and provider compensation. The beginning of this streamlined delivery involves capturing a picture of best care and mapping the cost of processes of care. The initial investment of TDABC in researching these care costs at the patient level can be a huge barrier for healthcare systems with small margins and limited resources. This alignment is an investment in your long-term viability and success.
Once you understand your underlying costs to deliver care, health systems will be better prepared to negotiate value-based payment contracts with payers and direct-to-employers. Pair your measurement of costs with your outcomes. Integrating care delivery with outcomes standards has improved in recent times through ICHOM. Medical systems need to incentivize health if healthy patients are a priority. The analysis of specific costs to a system needs a better reporting system than a charge master or traditional EHR which is strongly designed toward recording fee for service work. We must align or incentives and our health IT with our desired outcomes in healthcare. The more billing codes I can create in an electronic health record, the more I am reimbursed. Reimbursement alignment should match desired outcomes and physicians operating at top of their license.
Under value-based care, health and well-being become a priority whereby often in the fee-for-service model, sickness can be the priority because you get paid by doing more interventions, which may not lead to the best outcomes. The careful measurement of care (i.e. TDABC) paired with standards of best care will improve care delivery and reduce the cost of that care delivery. Insights about improved models and standards of care for outcomes and healthcare delivery allow patients, providers, and administrators to align with the shared goal of healthier patient populations. I am looking forward to the data infrastructure to catch up with these goals of better care delivery and a great patient experience.