4 strategies to connect insights and care teams to scale value-based care

In the United States, health systems are trying to achieve size and scale for long-term sustainability through collaborations and mergers and acquisitions. While these efforts may improve efficiency, they don't always generate the breakthrough innovation that value-based care models demand. To transition to value-based care, the health network of the future must deliver better health outcomes by operating smarter, faster and in a more coordinated manner.

Becker's Hospital Review recently spoke with three healthcare leaders about how their organizations are mapping the journey to value-based care. Nishant Anand, MD, executive vice president and CMO at Clearwater, Fla.-based BayCare Health System; John Kravitz, CIO at Danville, Pa.-based Geisinger Health System; and Bharat Sutariya, MD, vice president and CMO, population health at Cerner, offered their thoughts on connecting insights and care teams in agile ways. Key strategies, include:

  • Creation of a connected health network
  • Increased focused on holistic care
  • Innovation and experimentation using artificial intelligence and machine learning
  • Promotion of incremental and disruptive change

Why scaling value-based care is difficult

Shifting to value-based care models is critical for health systems. Yet many organizations continue to do the same approaches and expect different results. To transform care delivery and achieve better outcomes, services must be redesigned and redefined. Data, analytics, insights and workflow integration all play a central role.

"The opportunities for improvement aren't always clearly identifiable. That's where data and analytics come into play, " Dr. Anand said. "When we look at where data leads us, rather than focusing where we intuitively think the opportunities are, we tend to be more successful."

In response to the Meaningful Use and the ACA, most health systems achieved near universal EHR adoption. While EHRs are an important asset in optimizing care delivery, they alone don't inherently support value-based care beyond care transactions. To support proactive and accountable care management, organizations also need systems that aggregate, standardize and reconcile data to a comprehensive and longitudinal profile for each patient.

Strategy 1: Creation of a connected health network

According to Mr. Kravitz, system integration is imperative to promote availability of accurate and complete data to all providers and other care team members. Garnering deep relationships with vendors that are less specialized and more versatile is also helpful to streamline costs, improve agility and support digital strategies. Mr. Kravitz said, "We saw the value of having a scalable system that could aggregate data from multiple sources both inside and outside our organization. As a result, Geisinger decided to implement the Cerner HealtheIntent® platform."

HealtheIntent is an EHR-agnostic, cloud-based data and insights platform. The technology enables organizations to aggregate, transform and reconcile data in a fashion that supports a wide and growing span of value-based care initiatives.

Geisinger Health System is building a technology stack — which includes HealtheIntent — that will help facilitate real-time or near real-time integration of actionable data into the EHR at the point of service. The application integration layer of this technology stack is a critical element.

"The application programming interface (API) integration layer will simplify our technology stack by supporting electronic data interchange (EDI) transactions, HL7 compliant transactions from the clinical enterprise and real-time integration," Mr. Kravitz said. "The integration layer to support real-time communication with advanced program integration is very important. I think it will be the Holy Grail for us to bring data back and forth quickly."

Strategy 2: Increased focus on holistic care

A foundation of enterprise-wide data is essential for enabling holistic care and enhancing the digital experience. Diverse data sources can be turned into meaningful information where a network of providers and other care team members can act. "We have a lot of data on our patients, but we need to aggregate it and turn it into useful information and analytics. Our collaboration with Cerner has been instrumental in accomplishing this goal," Dr. Anand said.

Longitudinal records — organized, comprehensive health profiles collected over time — enhance patient context and rely on rich data from inside and outside the organization. Longitudinal records include information on clinical data, financial claims data, pharmacy benefit manager information, social determinants of health and more.

"We must understand the health and care ecosystem that surrounds a person so that we can fully leverage resources to address patient risks and needs for better health," Dr. Sutariya said. "Cerner has built layers of surveillance and intelligence that proactively attribute patients to providers, identify risks, measure care gaps and generate recommended actions."

BayCare Health System has leveraged technology to address patient risks and needs through the following strategies:

  • Intelligent medical surveillance. Population-, provider panel and patient-level alerts can be generated through the application of algorithms and predictive models, providing insight to quality, cost and utilization. For instance, chronic condition registries enable health systems to identify patient care gaps, stratify population by gaps in care severity and help administer preventive screenings. BayCare Health System has further augmented care gap management by launching remote monitoring for patients with chronic conditions. Remote patient monitoring provides an extra layer of support to high-risk individuals and can help prevent crisis situations.
  • Population health. BayCare Health System has population health experts who continually look through data. They contact patients and recommend care after a hospital discharge. Dr. Anand noted, "While the individual provider and patient experience is important, we must be proactive and reach out to people before they need our care or before it's too late."
  • Digital health. Some legacy health IT systems haven't made the transition to mobile environments that both patients and employees prefer. Mobile is a key factor driving the digital strategies of many health systems. BayCare Health System has developed a telemedicine platform called BayCare Anywhere which enables patients and community members to get care 24/7. BayCare Health System has also installed kiosks in grocery stores so people can take their blood pressure, monitor their vital signs and conduct telemedicine consultations.

Strategy 3: Innovation and experimentation using AI and ML

Compared to other industries, the healthcare sector has been slow to adopt analytics, artificial intelligence (AI) and machine learning (ML). However, many health systems are now exploring how to use these technologies to support value-based care.

Geisinger Health System's data scientists are working in conjunction with the clinical enterprise on innovative projects based on AI and ML. "The human eye can't see early stage cancer cells, but computers can pick up sub-microscopic components that are starting to form. This knowledge is beneficial for early diagnosis and treatment," Mr. Kravitz said.

BayCare Health System is partnering with several companies with the goal of enhancing its use of AI and ML. The organization is also exploring the use of chatbots and the automation of some care processes, such as presurgical optimization and post-surgery care, that traditionally would have required a care manager. This type of automation enables the organization to serve larger populations.

"I see the future as being pretty bright when it comes to AI and ML," Dr. Anand said. "That's where true disruption is going to occur. If we can automate certain aspects of healthcare through machine learning and rapidly improve processes, we can change health for the better."

Strategy 4: Promotion of incremental and disruptive change

Health systems are challenged to move toward the value-based care models of tomorrow while still maintaining performance in today's primarily fee-for-service world. To support the journey to value-based care, organizations must focus on transformation in three areas:

  • Transactional efficiency. Transactional efficiency includes both efficiency and appropriateness of services. Dr. Sutariya explained, "We're focused on supporting that each transaction occurs in the most appropriate venue by the most appropriate licensed provider or care team member."
  • Workflow and operational efficiency. Workflows must be optimized for both clinical and supportive care team members. Data insights can be used to inform and guide optimization of workflows and reduction in operational variance.
  • Clinical care delivery optimization. The goal is to deliver the best outcomes for patients, while promoting efficient provider workflows. Organizations can leverage technology to gain and sustain momentum across these strategies.

BayCare Health System has leveraged these transformation efforts to support incremental improvements and future innovation. The objective of BayCare Health System's care transformation initiative is to improve care, decrease costs and improve the patient experience.

"Looking to the future, we started a population health project, which focuses on upstream care. We are looking at all aspects of member and patient care, including mental well-being, food and nutrition needs, and community connectedness," Dr. Anand said. "We have bifurcated our transformation work. The bifurcation enables our acute team to make the incremental improvements needed to be successful today, while our population health team identifies the giant leaps and improvements required for the future."


Healthcare systems can't ignore the urgency of modernizing care delivery and optimizing their networks. Consumers, payers and health systems all appreciate healthcare is complicated, fragmented and expensive. Mr. Kravitz observed, "It's not going to be fee-for-service forever. When healthcare reaches 19 percent or 20 percent of GDP, it's a tipping point that indicates we are spending too much on healthcare. Health systems of all sizes must get on the bandwagon and start looking at population health." Data and technology can help health systems with the transition to value-based care. According to Dr. Anand, technology can provide accurate and actionable information across the ever-growing care team, so all patients receive "the best care every time, everywhere they go." "Let the data drive where opportunities lie and hardwire those insights into care delivery through technology," Dr. Anand said. "That will result in the best outcomes for people, which is what we're all trying to achieve."

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