Perspectives

EHRs: From data repositories to powerful workflow engines

Health Care Current | October 9, 2018

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies, and provides updates and insights on policy, regulatory, and legislative changes.

My Take

EHRs: From data repositories to powerful workflow engines

By Steve Burrill, vice chairman, US health care leader, Deloitte LLP

National Health IT Week kicked off yesterday and will run through Friday. This annual nationwide awareness week focuses on how technology can drive change and improve the US health care system. One area that has tremendous potential to drive change is the electronic health record (EHR). But there is much room for improvement, specifically around physician engagement and interoperability.

Driving change through physician engagement

While EHRs are nothing new, many clinicians continue to struggle with them and dislike the accompanied administrative work. For every hour a physician spends with a patient, he or she might spend an additional two hours tapping data into an EHR or completing other administrative tasks.1 Some physicians end up completing their EHR work at home after hours—something one organization dubbed “pajama time,” according to our report on physician-alignment strategies.

To dig deeper into physician attitudes related to EHRs, the Deloitte Center for Health Solutions surveyed 624 US primary care and specialty physicians. More than half (58 percent) said they see clinical documentation as an area in need of improvement, and 36 percent saw documentation as a daily task that is ripe for better automation. These tasks include charting, capturing visit notes, data entry, and inputting information to meet administrative billing requirements.

Although physicians are important stakeholders, some of our survey respondents said they felt like passive participants when it came to EHR improvement efforts. Only 34 percent of all physicians that we surveyed said they had been asked by their organization or an EHR vendor to provide feedback on EHR enhancements. Interestingly, 44 percent of primary care physicians said they had been asked to provide feedback. Primary care physicians were early adopters of EHRs and many of them have more experience with the technology. This could be because the Medicare and Medicaid EHR Incentive Programs, which provide financial incentives to adopt and demonstrate meaningful use of EHRs, were most applicable to primary care physicians.

Health systems should consider ways to solicit feedback from their physicians. According to our research, there is a link between inviting feedback and sustaining engagement. About half of physicians who said they were not asked for feedback also said they were unaware of any efforts to improve EHRs. Among the physicians who were asked to provide feedback, just 16 percent said they were unaware of improvement efforts. While feedback won’t necessarily lead to more functional EHRs, it could help the health system’s informatics teams understand some of the challenges physicians encounter—and develop comprehensive solutions.

Improved interoperability could keep the trains running

More than 60 percent of the physicians we surveyed agree that EHR systems need to be interoperable. But this is a complex issue with no easy solution. As many health systems have grown through mergers and acquisitions, they have been left with a variety of EHR systems that often can’t talk to each other.

The need for interoperability is not unique to health care. Early in this country’s history, railroads operated regionally and there was no standardized gauge for the tracks. To build an interoperable intercontinental railway system, the nation’s railroad operators had to agree on the gauge of track and types of cars that would be used. In some areas, miles of track had to be replaced with the standardized version.2

Similarly, hospitals and health systems might need to move toward a standardized EHR platform or connect multiple platforms through interface engines. Internal and external stakeholders will likely need to come together and agree on standardized governance and documentation requirements. We appear to be heading in this direction.

The 21st Century Cures Act of 2016, for example, requires the US Department of Health and Human Services (HHS) and the Office of the National Coordinator for Health Information Technology (ONC) to improve the interoperability of health information. Over the next few years, ONC is expected to establish a Trusted Exchange Framework and Common Agreement to improve data sharing across disparate health information networks.

Improvements in interoperability could help reduce duplications and limit the need to chase down patient records. This would likely lead to more accurate and complete clinical information. Rather than relying on patients to relay information, clinicians could more easily access the original sources (e.g., procedures, tests results, medication/dosages).

It wasn’t long ago that patient medical records existed only as paper documents in color-coded folders housed in massive metal filing cabinets. Efforts to move away from paper records began in the early 1960s, and Lockheed Corporation is credited with developing the predecessor to the modern EHR in 1971.3 In the decade that followed, academic medical centers developed their own variations, and the federal government implemented its Decentralized Hospital Computer Program for the Department of Veterans Affairs.4 

Many hospitals have made substantial investments in data and operations-management systems for EHRs, supply chain, and revenue-cycle functions. Health system leaders should consider devoting resources to train and retrain clinicians on how to use EHRs effectively. EHRs that serve as powerful workflow and analytics engines could be particularly important as health systems move toward value-based care. The technology behind EHRs is complex and not always easy for some clinicians to use. Creating a culture where clinicians are rewarded for seeking technical help could be an important step forward.

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1 Annals of Internal Medicine, Putting patients first, May 2, 2017 (http://annals.org/aim/fullarticle/2614079/putting-patients-first-reducing-administrative-tasks-health-care-position-paper)
2 Library of Congress, The Transcontinental Railroad (https://www.loc.gov/collections/railroad-maps-1828-to-1900/articles-and-essays/history-of-railroads-and-maps/the-transcontinental-railroad/)
3 The American Health Information Management Association, EHR Evolution: Policy and Legislation Forces Changing the EHR (http://library.ahima.org/doc?oid=105689#.W6u2JHOWxpw); American Medical Association, Development of the Electronic Health Record, March 2011 (https://journalofethics.ama-assn.org/article/development-electronic-health-record/2011-03)
4 US Department of Veterans Affairs, History of IT at VA (https://www.oit.va.gov/about/history.cfm)

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In the News

Biologics will have 10 years of exclusivity under trade deal

The revamped North American trade deal, the US-Mexico-Canada Agreement (USMCA), protects new biologic drugs from generic competition for a period of at least ten years. Canada currently protects biologics for eight years, while Mexico’s protection is limited to five years. Existing US laws protect biologics from generic competition for 12 years. Biologic drugs, which are typically derived from living organisms and administered via infusion or injection, are among the costliest medicines in the market.

The White House published the USMCA online on October 1, and leaders from the three countries could sign the agreement as early as November 29.

CMS releases 2019 Medicare Advantage and Part D program information

On September 28, the US Centers for Medicare and Medicaid Services (CMS) released 2019 premium and benefit information for Medicare Advantage (MA) and Part D prescription drug plans. In a fact sheet released the same day, CMS projects 22.6 million people (36.7 percent of all Medicare beneficiaries) will be in MA plans—an 11.5 percent increase from 20.2 million enrollees in 2018.

According to CMS, MA and Part D beneficiaries can expect the following changes in 2019:

Lower monthly premiums: Average monthly premiums for MA plans have been declining since 2015. For 2019, the agency predicts the average monthly premium will be $28—a $1.81 decrease from 2018. The agency estimates that 83 percent of MA enrollees will have the same or a lower monthly premium compared to 2018, provided they stay on the same plan. About 26 percent of MA enrollees who stay on the same plan in 2019 will see lower premiums, and approximately 46 percent of MA enrollees who stay on the same plan will pay nothing in premiums in 2019. On the Part D side, the average monthly premium in 2019 will be $32.50, which is 3.2 percent lower than 2018, according to CMS. The decrease in Part D is the second in two years.

Expanded plan options for beneficiaries: According to CMS, access to MA and prescription drug plans will remain constant, with 99 percent of all Medicare beneficiaries having access to at least one health plan in their area. Additionally, all Medicare beneficiaries will have access to at least one Part D plan. Nationwide, CMS predicts there will be 3,700 MA plan options in 2019, compared with 3,100 in 2018. More than 90 percent of all Medicare beneficiaries will have access to 10 or more options in 2019—an increase from 86 percent in 2018.

Increased supplemental benefits: In a final rule released in April, CMS provided greater flexibility to MA plans around benefit design (see the April 24, 2018 Health Care Current). The agency predicts that nearly 270 MA plans will provide nearly 1.5 million enrollees with new and expanded supplemental benefits, such as adult day-care services and in-home caregiver support. MA enrollees with certain health conditions, such as diabetes or congestive heart failure, could see lower cost sharing and more benefits aimed at those conditions. According to CMS, access to dental, vision, and hearing benefits will also increase.

In August, CMS also expanded flexibility for Part D plans’ utilization management and enrollee incentives, specifically to allow for innovative formulary design (see the September 11, 2018 Health Care Current).

(Source: CMS, 2019 Medicare Advantage and Part D Prescription Drug Program Landscape, September 28, 2018)

CMS launches eMedicare initiative to improve user experience

On October 1, CMS announced the eMedicare initiative—a multi-year effort designed to improve beneficiaries’ experience in finding coverage. CMS announced the launch with an online video. According to CMS Administrator Seema Verma, the agency intends to implement digital capabilities to enhance and improve existing Medicare resources. Some eMedicare highlights include:

  • An online “coverage wizard” for beneficiaries to compare traditional Medicare to MA plans.
  • A standalone, mobile out-of-pocket-cost calculator to provide information on overall and prescription drug costs.
  • An updated method for logging into the Medicare Plan Finder tool, which allows beneficiaries to search for plans. Beneficiaries can log in using an online account, rather than entering five pieces of information to authenticate.
  • Some beneficiaries will have access to a web-chat option in the Medicare Plan Finder tool.

Open enrollment for Medicare begins October 15. According to CMS, about 10,000 people join Medicare each day, and as of 2016, 65 percent of beneficiaries use the internet daily or almost-daily. The Medicare population is expected to increase to more than 80 million by 2030, up from 54 million in 2015.

(Source: CMS, CMS announces new streamlined user experience for Medicare beneficiaries, October 1, 2018)

CMS extends Part B penalty relief

Medicare-eligible seniors who were enrolled in an exchange-based plan will be allowed to switch to Part B without facing a penalty for one year, according to a September 28th announcement from CMS. The announcement came close to the September 30th deadline for seniors to contact the agency and request penalty relief to switch to Part B coverage.

The Part B late-enrollment penalty is based on the amount of time a consumer delays enrollment, starting from the date the consumer first becomes eligible. The penalty increases the monthly Part B premium for that beneficiary forever.

The deadline change is consistent with requests from senior advocates, insurers, and providers to extend the relief policy. Among those most affected by the penalty are seniors who mistakenly enroll in exchange-based coverage and are not familiar with Medicare’s rules. CMS has updated its Medicare enrollment communications and intends to ensure that all individuals receive information about the implications of delayed enrollment.

Related: CMS recently updated its Medicare Program Integrity Manual to clarify how Medicare administrative contractors (MACs) develop or update local coverage determinations (LCDs). These manual changes include:

  • A step-by-step roadmap explaining the LCD process 
  • Standards for presenting evidence used in the decision-making process
  • Implementing a new process for stakeholders within a MAC’s region to request a new LCD
  • Retiring any policies not finalized within a year
  • Changes to Contractor Advisory Committees to expand participation and make meetings more accessible and transparent

If there is no CMS-developed national coverage determination available, local MACs must decide whether—and to what extent—a particular medical service should be covered within their geographic region. The 21st Century Cures Act, which was signed into law in 2016, called for CMS to improve the transparency and consistency of the LCD process.

(Source: CMS, Summary of Significant Changes to the Medicare Program Integrity Manual Chapter 13 – Local Coverage Determinations, October 3, 2018)

More large employers offer health risk assessments, telehealth coverage

About 70 percent of large employers that offer coverage provide workers with opportunities to complete health risk assessments, and 38 percent offer incentives to participate, according to the results of the Kaiser Family Foundation’s 2018 Employer Health Benefits survey. Among those employers, one in five (21 percent) collect some information from workers’ mobile apps or wearable devices as part of a wellness or prevention program, an increase of 14 percent from last year. Additionally, 74 percent of large employers cover telemedicine services—up from 63 percent last year and 27 percent in 2015, according to the survey results.

The study also found that family premiums for employer-sponsored health coverage averaged $19,616 for 2018—up 5 percent from the previous year. Employees pay an average of $5,547 of the cost and the employer covers the rest. While rate increases have been stable, 85 percent of employees are responsible for an annual deductible—up from 59 percent 10 years ago.

The study is based on a survey of 4,070 public and private employers conducted during the first half of 2018.

(Source: KFF, Premiums for Employer-Sponsored Family Health Coverage Rise 5% to Average $19,616; Single Premiums Rise 3% to $6,896, October 3, 2018)

Survey: Employers are experimenting with new cost-containment strategies

Almost half of employers are experimenting with health plans designed to foster new approaches to providing care, according to the results of a survey from the National Business Group on Health (NBGH) (see the October 2, 2018 Health Care Current). According to NBGH, employers that are not engaging in cost-containment efforts expect health care costs to rise by 6 percent in 2019. However, employers that incorporate traditional containment strategies into their plan designs still anticipate a 5 percent cost increase in 2019, NBGH noted. More than one-third of employers expressed concern with small groups of high-cost patients.

According to NBGH, close to 50 percent of the participating employers are actively working on strategies aimed at providers and beneficiaries. Among survey respondents:

  • 35 percent are directly contracting with accountable care organizations (ACOs) or high-performance networks (HPNs).
  • 58 percent are planning to offer employees self-directed resources for mental health concerns in 2019.
  • 65 percent expect to offer employees tools for managing their health claims in 2019.
  • 95 percent of large employers in the US offer telehealth consults to their employees

Breaking Boundaries

Conference highlights innovations in pediatric medical devices

At AdvaMed’s annual conference last month, six companies received awards for devices that address significant unmet needs in children’s health care. The contest is a joint effort between AdvaMed’s Medtech Conference and the Pediatric Device Innovation Symposium.

All the winning devices target pediatric heart disease. The devices are small, and many are made with materials that can grow with the children. In some cases, the devices could help reduce the number of invasive procedures and surgeries for children who have heart disease. Each year in the US, an estimated 40,000 children are born with heart disease.

The winning devices include:

  • Bardy Diagnostics’ Carnation Ambulatory Monitor (CAM), a single-use, continuous-recording, ambulatory ECG monitor that records for up to seven days. The device is the size of a bandage and children can wear it over their hearts. The CAM patch connects to a suite of ECG analysis services and tools. After EKG data are collected, a web-based portal uploads and analyzes the data. The portal can securely access and manage patient reports.
  • Draper’s LEAP Valve, which is designed for newborns and children up to age six, passively expands to a two-fold diameter to accommodate the child’s growth. The device could help children avoid as many as three to five major surgeries to replace valves that fail or are outgrown.
  • Polyvascular’s minimally-invasive pediatric pulmonary valve replacement is designed for young children who have congenital heart disease. Most replacement valves are sized for teens and adults, which means there is a gap in the market for children. The stent-mounted valve is compatible with vessel sizes in small children, and the material is expandable to accommodate a child’s growth. 

Each award winner received $25,000 and advisory services from the Sheikh Zayed Institute’s innovation resource network to help them try to bring their products to market.

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