Everywhere you look data can be captured (health care applications, personal monitoring devices, etc.), but when, what, and how the data is presented to a provider determines it meaningfulness. Data forms traditional sources have varying levels of specificity from Payers (claims and Payer distributed reporting), EMRs, PHRs, laboratory systems, practice management systems, radiology information systems, and impactful medical research is exploding. Each of these data sources has specific use ability, but these data sources are not always available at the “time of service” when treating patients acutely.
In a perfect world, all of these data sources would be available instantaneously and through sophisticated clinical decision support, current medical literature, all available patient data, and evidence based cost effective interventions could be presented to the provider to guide the most optimal plan of care individualized to the patient. If changes in technology weren’t challenging enough, healthcare delivery is in the middle of transforming into a value-based reimbursement model moving away from fee-for-service. Medscape’s Physician Lifestyle Report 2015 indicates that 50 percent of physicians are experiencing “burnout”. Burnout is caused by too many bureaucratic tasks, too many hours at work, income not reflecting the hours worked computerization of practice, impact of the Affordable Care Act, challenge to offer continuous high quality care to increasing patient demand, and lack of fulfillment as reported by Carol Peckham. Physicians now must know how to participate in Medicare Shared Savings Program, Medicare Advantage, quality enhanced reimbursement, bundled payments, and other reimbursement models. The Medicare Access and CHIP Reauthorization Act of 2015 essentially minimizes focus on fee-for-service payments and fortifies the move to quality and value based reimbursement models. More than ever, physicians must remain engaged and knowledgeable to the “rules” to reimbursement to achieve success in quality/ performance based reimbursement.
“The business of medicine is proving to add significant burden on physicians and healthcare team members”
Information technology vendors are furiously working to meet demand for interoperability, and enhanced functionality, but what actually happens at the time of service? The physician or midlevel provider works hard to offer timely comprehensive care, access and review many data sources, but is constrained by time and schedule to effectively research, accumulate, interpret, and summarize every data sources during the patient visit. This disharmony or lack of interoperability limits the effectiveness of data in patient care. So what can a physician or healthcare organizations do to face these multivariate challenges?
In order to be successful, every month each provider must know the patients that are attributed to them by Payer and their status meeting the quality measures determining quality incentives. Within that list, the most chronic or medically problematic patients are identified, allowing their team to interact and “manage” or reduce barriers to effectively care for these patients. Ultimately, the physician is supported to limit the possibility of these patients get sicker. Each provider receives their care gaps (medical procedures or testing as approved by the United States Preventive Services Task Force), and other nationally recognized markers of quality to assess their management of patients with chronic or acute illness. Additionally, patients must receive annual well visits to maintain good health. All of these measures are reported back to the physician to provide short term requirements to serve their patients, but also indicates their internal knowledge and processes to care for their patients. Knowledge of where and for what illness their patients seek alternative care is vital to helping patients with their medical conditions. Today, physicians’ patients who use emergency departments, or are admitted to the hospital are reported with the goal to minimize improper use of these facilities. A patient with congestive heart failure should be managed aggressively in the outpatient environment, and if admitted without other causes, the admission is deemed inappropriate. If a patient seeks care in the emergency department for sore throat, that too is categorized as inappropriate. Should the patient be seen in the office or urgent care, the patient should receive a throat swab to quickly provide insight, but a culture is the gold standard to diagnose bacterial pharyngitis. This patient will be evaluated for receiving the right test and timing of antibiotic use. The CHF patient will be monitored for timeliness of medication refill. Each of the metrics are calculated and used to determine success in a quality-based reimbursement model. If specific reporting on a recurrent monthly basis reflecting the rules of reimbursement, how would a physician gain insight into their level of quality care? Now more than ever, reimbursement models are incentivizing physicians to manage their patients more aggressively in post-acute care settings such as skilled nursing facilities, and home health.
Primary care providers are working hard to meet patient centered medical home certification. Achieving certification prepares the office to manage each patient at the local level. Through participation with a larger organization, the population can be managed using care coordination. Today, effective patient care to meet the quadruple aim requires significant teamwork with all providers caring for the population. Each team member needs access to current data that summarizes the patient’s transition through each phase of care. Since a single piece of technology is not sufficient, healthcare organizations rely on operationalized reporting of patient data with adequate frequency to successfully perform medical management services. Today population health or medical management uses multiple technological solutions with varying degrees of interoperability. At a minimum, actionable reporting must be available to physicians, care coordinators, case managers, and any other professional involved in direct patient care.
Directed timely actionable and current information is required to provide unique population and patient specific data allowing the engaging healthcare provider information to meet and exceed the expected necessary benchmarks to successfully meet the requirements of new reimbursement models. Consider CMS’ Bundled Payment Care Improvement Initiative. The goal is to manage the patient from admission through all phases of care without exceeding the target cost of the initiating event. To achieve success, the patient must be identified at time of admission to the hospital, discharged timely, and if necessary transferred to a post-acute care facility based on accepted evidence, without exceeding the expected length of stay without readmission. Communication and data sharing at every phase of care to multiple providers through information technology solutions and reporting allows an organization to take the challenge and successfully limit their exposure while taking the economic “risk” of participating with the program.
Data means success. There will not be one solution, one reporting structure, one process. With the diversity of healthcare organizations come diversity in operational solutions to insure data can be used effectively. How data is used and operationalized will determine the organizations long-term success. The team is not singularly composed of a physician, but rather the team working together to serve the population one patient at a time!