Blog Post

Roadblock to Reform: How Health IT is Hindering The Pay-for-Quality Movement

Upgrades to tech built to address administrative tasks associated with a fee-for-service healthcare paradigm won't cut it in the pay-for-quality era.

Erica McDermott
5 min read
August 25, 2016
image representing roadblock to reform: how health it is hindering the pay-for-quality movement
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You’ve heard the expression about putting lipstick on a pig, right? You could do it, sure—but it doesn’t change the fact that it’s still a pig. In other words, you can’t make superficial changes to something and expect those changes to alter the true nature of whatever it is you’re trying to dress up. This holds true whether we’re talking about a political candidate’s campaign strategy or, as is the case in this post, a product—like an electronic medical record (or health) system. Superficial upgrades to the EMRs and EHRs that were built to accommodate a fee-for-service healthcare paradigm aren’t going to be enough to level those systems up to this new pay-for-quality environment. (Some might argue that many of these systems don’t actually meet providers’ fee-for-service needs, either. But, I digress.) It’s going to take more than a little lipstick to make these already-outdated systems anything more than relics of a bygone era. Here’s why:

As it stands, healthcare data isn’t being used to inform clinical decision-making.

According to Apixio CTO John Schneider—the author of this HealthData Management article—the US healthcare system produces 1.2 billion clinical documents each year. That’s billion—with a “B.” Unfortunately, ”the data in those documents is not used as fodder for more informed clinical decision-making.” That’s because the health IT that’s been supporting our fee-for-service payment model has really been nothing more than “an adjudicated claims stream to state what services were provided that required payment.” In other words, the systems aren’t equipped to help providers use data or data analytics to better understand—and improve upon—their care.

Most EHRs are products of the payment environment in which they were built.

While undoubtedly frustrating, this is not all that surprising given the history of technology adoption in the healthcare industry. As Schneider points out, less than a decade ago, most providers were documenting on paper. Then, in 2009, the HITECH Act offered providers some incentive to make the transition to electronic documentation—which increased the number of providers and organizations using EMRs/EHRs. However, the tools available at the time were mostly “point-of-sales systems whose purpose was to facilitate the business side of healthcare.”

While the Meaningful Use (MU) rules were developed to foster, well, meaningful technology use, there’s been a lot of controversy about their merit and effectiveness. According to Schneider, much of the backlash has occurred because these EHRs weren’t designed or developed with collaborative care or value-based payment models in mind. Rather, they’re products of the environment in which they were built: “At their core, EHRs were architected in a fee-for-service environment to improve clinician workflows and optimize billing,” Schneider said. “To accomplish that goal, they don’t require complete knowledge of patients. However, in a value-based environment, complete knowledge of a patient's health is critical.” Ruh roh.

Our new IT-enabled industry is having a hard time catching up.

Today, 95% of all hospitals and 75% of all physicians are using an electronic documentation platform. However, many of them aren’t thrilled about it. In his article, Schneider includes the results of a study conducted by the Mayo Clinic and the American Medical Association: While just under 60% of the physicians surveyed believe EHRs improve patient care, a little more than 60% reported that EHRs don’t improve operational efficiency. In other words, providers are forced to use software that they they believe “only impose[s] social and time costs without markedly improving care.” According to Schneider, “the healthcare industry is struggling to come to grips with the fact that it’s no longer a people-and-paper enabled industry, but rather a people-and-information technology enabled industry.” And the current IT-enabled industry is lagging behind: “the technology and tools haven’t had time to accommodate to the richness of clinical data,” Schneider said. Case in point: “80% of the data in EHR clinical records is unstructured and thus difficult to access outside of the clinical setting for which the EHR systems were developed.” (Looks like PTs aren’t the only providers struggling to amass meaningful data that can be understood outside of their own arena.)

But everything else in health care keeps moving forward.

As I discussed in this post, the MU program—at least in the form in which we’ve come to know it—will be replaced by the Medicare Access and Chip Reauthorization Act (MACRA), which is the umbrella program for the Merit-based Incentive Payment System (MIPS). Whereas MU required all eligible professionals to use an EHR that was Meaningful-Use certified, MIPS is taking the focus off of the technology itself and placing it on the outcomes clinicians are able to achieve through the use of technology. While this certainly seems like an improvement, it doesn’t address the real problem: “The recently proposed rules have made significant progress toward making the new framework less rigid and more valuable,” Schneider wrote. However, “the issue remains that we will be adapting systems that are designed for a pay-per-service model rather than an actual model of a patient’s state.”

In order for healthcare IT to evolve, we must prioritize data.

As a result, he says that EHR systems must “walk a fine line,” meaning that “if EHRs stray too far from the status quo of supplying the claims streams that have been the financial lifeblood for healthcare organizations, then provider organizations that use them have a problem.” When push comes to shove, financial and management features seem to trump data capabilities—but that’s not sustainable, because healthcare IT will only evolve in the way we need it to if providers and technology vendors start prioritizing data, too. So, how does the industry as a whole go about making this shift? Based on Schneider's advice, here are the two most important changes that need to take place in order for IT to be effective in this new healthcare paradigm:

  1. Providers must change their expectations about what an EMR/EHR can and should do; and
  2. Developers need to create systems that address the administrative and clinical needs of the providers who use them.

For developers to create these systems, though, providers need to start asking for—nay, demanding—them. (This further underscores the importance of nixing generalist systems in favor of specialty ones.) According to Schneider, “the ability to combine data from EHRs with clinical data from...notes, insurance claim data, pharmacy data, laboratory tests, [and] patients themselves...will lead to better care outcomes.” This type of a system—one that “combines both clinical and transactional data”—will enable providers to “understand patterns to improve care” and receive incentives for doing so.

What do you think about the current state of healthcare technology? Is the healthcare IT industry putting lipstick on a pig—or do you feel EMR and EHR companies are making real progress toward the goal of meeting providers’ needs in this new pay-for-performance era? Tell us your thoughts in the comment section below.


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