Becoming Accountable: Delivering Value-Based Care Through Optimal Use of IT and Data

by Craig E. Samitt

As the leader of an organization that has been "accountable" for nearly three decades due to our long-standing ownership of a health plan and our strategic focus on value over volume, I'm often asked to reflect back on our journey and to highlight the tactics we've implemented to achieve success. The two most crucial drivers of our transformation at Dean Health System have been our willingness to embrace the use of technology and the effective use of data to drive decisions and motivate change.

While we've made great progress in becoming a technologically and information-enabled health system, I don't want to say that we're perfect by any means. We have much further to go. Based on lessons learned during our transformative experiences to date, here are four predictions for the future of accountable care.

Prediction 1: Implementation and Meaningful Use of EHRs Will Not Be Sufficient

Over the course of my career, I've implemented an Epic electronic health record system three times, first at Harvard Community Health Plan, then at Fallon Clinic and most recently at Dean. While it's become clear to many of us that in this day and age, implementation of an EHR is essential to achieving high-performance as a system, my experience clearly suggests that implementation alone will not be sufficient. Likewise, while many health systems are working to maximize meaningful use attestation, meaningful use of EHRs will be essential (in fact required), but not sufficient, to be "accountable" in the future. 

Alternatively, I would argue that our greatest organizational success will be achieved only when we "optimally use" our technologies. In the future, we'll want to ensure that we're using EHRs to their fullest potential and that specific EHR capabilities that influence improvement in quality, preventive screening, service enhancements, patient adherence or cost reductions are maximally used. We'll want to identify which best practices decision support prompts we should use to guide clinicians to standards of care that are evidence-based. We'll want to optimize clinical use of EHRs, so that they are as proficient as possible and the technology is viewed as an enabler of productivity and satisfaction, not a detractor.

In recent months, studies have begun to emerge that suggest that organizations that have implemented EHRs have seen health care utilization costs increase. I am admittedly surprised by these results and would be interested in knowing whether we would observe different results when studying organizations that are optimally using EHRs rather than studying those that are minimally or meaningfully using EHRs.

Prediction 2: Health Information Exchange Will Become Mainstream

While many markets have struggled and some have succeeded in developing and effectively utilizing health information networks, it would be hard to imagine a future health care world without HIN as part of the mainstream. (In the field of banking, could we envision a world without financial information exchange offered in the form of ATMs?) In the Madison, Wis., marketplace, most health systems are Epic EHR users, and Care Everywhere has offered us a taste of what's possible when health information is confidentially and comprehensively shared with all clinicians who care for a single patient (even if they may practice in different organizations).

The benefits of information exchange are both readily apparent and measurable by those doing it, and it's quite clear that mainstream exchanges will be essential elements of our systems as we seek to improve quality, improve safety, lower costs and improve patient convenience.

Prediction 3: The Use of Technology in Health Care Has Only Scratched the Surface

Every year, I return to my business school to lecture about health care operations and the future of health care. In a recent lecture, I was asked to comment on where I thought the predominance of new jobs would be for health care MBAs in the coming years. I stressed my impression that health care technology and informatics would be the fastest growing, most capitalized and most underserved field.

We don't have to go much past the extensive interest and participation in the Healthcare Information and Management Systems Society conference in recent years to recognize the explosive role that technology will play in the future of health care. When we envision how widely technology has been utilized in other industries, we should fully expect that most health care systems will need to/want to implement such things as kiosks, Web portals, e-patient visits, telehealth (telestroke, telepsych), virtual units (e-ICU, e-Hospitalist), e-consultation, expanded surgical robotics, computer-enable triage systems, expansive online access to medical evidence, predictive patient diagnostic systems, sophisticated data analytics, remote patient monitoring, social media and other real-time health prompts to engage patients and others.

We have implemented, or plan on analyzing the merits of, such technologies at Dean, and I would predict that a key to our success in the future will be to technologically enable -- beyond EHRs -- our practices, hospitals, health plans and system.

Prediction 4: Accurate, Transparent, Predictive and Comparative Data Will Be Omnipresent

At Dean, we've all admittedly struggled with availability and accuracy of data. Because of our inability to access good data, we often times find ourselves "flying blind" as we seek out opportunities to improve quality, service or efficiency. Because of the general inaccuracy or lack of reproducibility of some data, using data as a persuasive tool to influence change has sometimes been a harrowing experience.

Despite the challenges and insufficiencies associated with access to data, we've found that even imperfect information is useful, as it provides us at least some fundamental guidance on where/how to improve as a system. As our industry moves even quicker and more completely toward value over volume, our customers will want to access readily available information about our performance so that accurate comparisons can be made between competitors.

As we evolve from a system of unit-based care to population-based care, we, as systems, will want to be able to benchmark our performance against other organizations, share un-blinded comparative data with clinicians regarding service, quality and cost, and transparently report data to our markets as a means of growing our practices and competing in the world of health insurance exchanges. We also will want to develop comprehensive "big data" data warehouses and analytics shops so that we can predictively model clinical information, identify areas of quality/safety/cost concerns and assess variations in practice patterns. We'll also want to develop a wider array of metrics of success, so that we know what good quality looks like, what good service feels like and what efficient care costs. 

While our assessment of quality today is mostly process metrics in primary care, we can predict that we'll move closer to outcome metrics in the future, and such metrics will exist not only for primary care, but for all specialties and all services, both inpatient and outpatient. While we struggle with the accuracy, transparency, format and availability of data today, we've invested heavily in data creation, analysis, reporting and modeling at Dean because it is quite clear to us that data will be king in the world of value.

Bobby Gladd
See the Weeds' "Medicine in Denial." Improved population care has to come from improved patient-level care. And, yes, accurate, comprehensive, and actionable data must be at the fingertips of the caregivers (and patients themselves). __ "A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information. Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information..." [MiD pp 1-2]
Craig Samitt
Kim, thanks very much for your comments. I wanted to follow-up to your inquiry. I believe that reimbursement methodologies will continue to shift (by both public and private payors) to reward physicians/hospitals not just for how much they do, but for how well they do it. Once "pay for value" becomes the new normal, I would predict that providers will avidly seek out the adoption of EHR/HIE/Alternative technologies because such technologies will be essential to improve quality while reducing costs. I do not envision many more rounds of meaningful use incentives. HITECH has been effective in rewarding adoption and modestly effective use of EHR, but it will now be more comprehensive population-based payments/rewards and other drivers (e.g. market competition, transparency of performance data) that will incent "optimal use" of technologies.
Kim Slocum
I found this to be a very interesting piece and enjoyed its optimistic viewpoint. However, I'd very much like to hear what the author believes will be the driving force that makes all these positive changes occur. We've been talking about the importance of EHRs, HIEs, and other technology applications for a long time now. While EHR adoption has finally started to move in the right direction (thanks mainly to HITECH), other aspects such as community-wide HIE have struggled mightily. Many of the problems aren't related to technology but rather to business rivalries and cultural issues. Will future iterations of "Meaningful Use" be the driving force that gets us where we want to go? Will we finally see sufficient pressure from the payer community (both public and private) to make this happen? Would this still occur if we see drastic cuts made to the Medicare program next year? What we do know is that it's unlikely the provider community will change spontaneously.
evan yu
Digital healthcare is becoming increasingly important for easier access and maintenance. More and more digital platforms are rooting their place in medicine and thus will help more health clinics.
AJ Chen
Craig, thanks for the insight. I totally agree that EHR and MU are just the beginning. Patient data would need to flow as patients are served by different care providers. Patient data would need to fuel decision support to both patients and care providers. Once patients see direct benefits from having the digital health platform, patients will become the key driving force as well. So, in the short term, how to quickly use technology and data to engage patients in care is becoming critical, particularly for the underserved populations served by community health centers and clinics.

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