The adoption of electronic health records (EHRs) over the past decade and the corresponding development of value-based care and payment models have created opportunities for innovation, but many organizations have encountered barriers, whether technological, financial, or organizational. Challenges remain, but emerging information technology advancements are opening avenues to successfully implement bundled payment care models.
We suggest a four-part framework for health care systems to build value-driven technology applications to achieve success in bundled payments. This framework can be extended to other types of value-based models, though we focus on bundles. In addition, we identify gaps and offer examples of innovation within our health system and others that demonstrate early progress in addressing these. Our focus is on the technologic tools and the high-value activities that they enable, though aligning people and processes must be addressed in conjunction.
Health care leaders can easily appreciate why value-based care is needed, but understanding how to get there is not as simple.
Consider: In 2013, the Centers for Medicare & Medicaid Services (CMS) launched the Bundled Payments for Care Improvement (BPCI) initiative in which a set of services related to an episode of care is bundled into a single payment. By combining payments for physicians, hospitals, and post-acute care facilities into a single capped amount, CMS aims for providers to transcend traditional silos of care. More than half of the scenarios in BPCI are procedural episodes, ranging from major bowel surgery to coronary artery bypass grafts (CABG). By 2018, 832 hospitals and 715 physician practices had agreed to participate in the BPCI Advanced Model.
In creating this payment scheme, CMS has taken a standard policy approach — set up goalposts and allow organizations to innovate to achieve these goals. But goalposts are not a roadmap. Nearly half of BPCI participants in voluntary programs have dropped out, motivated by what we and other experts believe is providers’ lack of confidence in their ability to succeed in these arrangements when they are required to start taking downside risk. Without clear processes or tools at their disposal to buffer against downside risk, financial sustainability is murky.
For example, surgical teams will be held accountable for episode cost, though they are one of several providers influencing this outcome. Success requires sustained coordination and monitoring across providers in multiple locations with varying clinical approaches, care processes, and organizational cultures over a period spanning 90 days. Some aspects are under the direct influence of surgical teams, while other critical components are less so, particularly in the post-acute care period.
To achieve success, surgical teams and the network of providers involved in the episode need to coordinate an agreed-upon care plan, monitor the patient along the care pathway, and react appropriately when a patient’s needs change. The information systems architecture needed to enable these activities is beginning to coalesce. Though still a significant challenge, interoperability standards and cloud computing have improved the prospects of sharing data across facilities and remaining connected to the patient. EHR vendors now offer Web services that allow near real-time availability of clinical data. Pioneering health care organizations have built application interfaces to extract this data so that they can remain connected to the patient and aware of their care as they progress through the episode.
With these basic advances, the health care system can build value-driven technology applications for surgical teams and post-acute providers to achieve success in bundled payments.
A Framework of Information Technology to Enable People and Processes
There are four key aspects to this framework (Figure 1). These address essential aspects of the episode of care, including risk stratification, care team planning, care monitoring and communication, and patient engagement.
Risk Stratification and Prediction of Care Needs. Prediction of the patient’s specific care needs can help providers communicate expectations with the patient and allocate appropriate resources to their care. Two areas that are particularly helpful to anticipate, as they are important drivers of episode cost, are post-acute care facility utilization and hospital readmissions. Our system, Partners HealthCare, uses an electronic tool to predict post-acute care facility utilization and length of stay prior to an episode or at the time of hospitalization. The prediction is updated based on new information about the patient as it becomes available, including diagnoses and functional status. These data are communicated to patients by surgeons during their hospitalization and case managers initiate early conversations around discharge disposition. The length of stay estimation is communicated to facilities and monitored by transitional case managers who bridge the hospital and facility.
In collaboration with clinicians in the skilled nursing facilities, the transitional case managers help ensure that patient care continues to advance to give the patient the best chance for an efficient post-acute care episode. The combination of the prediction technology and the transitional case manager led to a 4.5-day decrease in adjusted average length of stay compared with controls who did not receive the intervention. Importantly, there was no increase in 30-day rehospitalization rates, indicating that these earlier transitions to home were made safely.
Readmission prediction algorithms have been the subject of numerous studies. Several efforts have validated readmission risk predictors for BPCI diagnoses such as joint replacement and CABG. By identifying high-risk patients, teams can focus greater resources on these individuals. In our system, this includes assigning the patient a care coordinator on discharge, scheduling outpatient follow-up within 7 days, and filling all prescription medications prior to departure.
Care Team Convening and Planning. Coordination of a unified patient care plan is critical to success and requires a shared platform to convene relevant providers. Transparency in the care plan can help drive evidence-based care and reduce unwanted variation. Coordination between inpatient and outpatient providers is pivotal as they often lack close relationships, even though post-acute care accounts for most of the variation in costs in bundles. Our system uses an electronic platform to track transitions of care from hospital to facility to home in real-time. Each hospital and the facilities in its preferred network can use the platform to transfer disposition of care plans and exchange messages. Other health systems have further strengthened transitions of care by using virtual handoffs via video conferencing and virtual rounding in which the hospital-based provider participates in rounds with the care team at the facility.
Care Monitoring and Communication. Throughout the episode, patients should be monitored for recovery and pathway adherence. EHR Web services allow continuous extraction of clinical data, such as vital signs, laboratory results, flowsheet information, provider-entered orders, and medication administration. One system improved care pathway adherence in their joint and spine bundles by offering standard postoperative order sets for providers and monitoring order entry data for deviations. This allowed them to not only guide order entry at the point of care, but also to track deviations from expected care and feed that information back to surgical teams.
In the post-acute care and home settings, patient recovery can be followed by devices that collect symptoms, vitals, and activity-related data and share this information with providers via the cloud. Evidence has been mixed as to whether greater at-home monitoring can improve outcomes. In our health system, we apply a telemonitoring program for patients predicted to have a high risk of readmission. At discharge, a visiting nurse brings the telemonitoring devices to the home and teaches the patient how to use them. These include devices that measure blood pressure, weight, and activity.
The data is fed back to care coordinators who can then reach out to the visiting nurse or patient directly. In addition, visiting nurses are equipped with a wound documentation mobile application that allows them to take high-resolution photos and route these to a central team of wound care specialists. Through this tele-wound service, wound care specialists can triage issues and either offer tips to the visiting nurse, perform an in-person consultation, or set up an urgent follow-up appointment in the surgeon’s clinic.
Patient Engagement. Patients and their caregivers must be meaningful partners in their pre- and post-hospital care. For example, our health system has incorporated messaging platforms that can automatically provide patients with text and video instructions prior to their scheduled procedures. These platforms can help ensure adherence, for example, to enhanced recovery pathways. In addition, patient-facing platforms that elicit patient-reported outcomes (PROs) can guide care teams regarding functional, mental, and social well-being and recovery. Our health system collects PROs using devices integrated with the EHR. PROs are specific to the type of surgery that the patient experienced. These data are reviewed with the patient during the postoperative office visit.
With this framework, we believe providers can enable the people and processes to achieve success on bundled payments. By developing the technology needed to support it, providers can fulfill the aims of bundled care envisioned by CMS and the potential of a health care system ripe for a transformation in care delivery.
We acknowledge that technologic tools seem far flung and often do not come together under a common vendor or singular platform. This is what makes it critical for providers to develop a clear, coordinated strategy for using technology to achieve the aims of value-based care. The data, now liberated through electronic records and made available to applications, is the engine. The chassis, however, is the framework that guides how technologies are integrated to serve one continuous patient experience. Leadership at provider organizations must establish this framework.