7 things to know about EMRs and care coordination

The financial pressures associated with expanding adoption of meaningful use and increasing urgency about value-based payment models are driving more hospitals and health systems to embrace care coordination.

The big emphasis is on improving utilization metrics and, ultimately, the organization's financial condition. Almost as default, hospitals are turning to electronic medical record (EMR) platforms to handle the important task of care coordination.

Care coordination offers significant benefits to patients, providers and payors by improving both clinical and business outcomes. And EMRs contain essential information to support care coordination. But the unique needs of different types of patients and treatments (e.g., inpatient acute care versus mainly outpatient, complex or chronic care) are so different that care coordination means very different things in different types of care settings. There is no one-size-fits-all way to do it properly.

Since care coordination is relatively new functionality for the prominent EMR vendors, clinicians and hospital management must bear in mind several fundamental facts about EMRs and care coordination.

1. EMR care coordination capability is limited. EMRs can likely have basic features added to handle the relatively straightforward tasks associated with inpatient care paths, such as discharge planning and utilization management for care that takes place primarily within the hospital. In these instances, care coordination is largely synonymous with inpatient case management, with the goal to conclude an acute care episode from the hospital's perspective.

While there may be instructions to make the patient aware of social services or support groups, there is no requirement to follow up or manage the patients when – or, more importantly, if – they engage such services. There is little or no functionality to support the idea that care coordination involves tracking, engaging and motivating patients toward long-term health goals or survivorship and across multiple facilities. There is no recognition that care coordination can and should extend beyond the walls of a facility to monitor and support patients as they transition to skilled nursing facilities, home care or other outpatient settings. In all likelihood, features that drive follow-up on patient referrals within individual hospitals may not be as effective or robust as those in purpose-built care coordination solutions.

2. EMRs were not originally designed for care coordination. It is no surprise that there are limits to the care coordination capabilities of EMRs as they were not originally designed for such tasks. They were designed several decades ago as digital versions of the traditional chart — a single point of information access about a patient's condition and clinical activities within single healthcare facilities. More to the point, EMRs were designed to be used by physicians, not nurses, administrative staff or other "care extenders" that play a large and growing role in healthcare.

So, as healthcare has evolved to be more reliant on outpatient care settings with more complex treatment plans involving multiple providers, EMRs naturally struggle to connect all the dots. This fragmentation is why we need care coordination in the first place: to help keep patients engaged and compliant with treatment plans that may involve more than just one facility.

So when we ask EMRs to do care coordination for patients with complex treatment plans, we are asking them to do something they were not designed to do.

3. Different features and data are required for outpatient and chronic care coordination. Outpatient specialty care coordination for patients with complex or chronic conditions requires a more robust and flexible approach. For example, spine patients typically see multiple providers (e.g., surgeons, physical therapists, physiatrists, etc.) at multiple facilities. Treatment plans might extend over many months or years. Specific metrics (e.g., Oswestry, Neck Disability Index, and STarT Back Tool) must be tracked to gauge progress.

Or consider oncology, where care coordination and patient navigation have been recognized as a best practice since the 1990s. Oncology care coordinators and nurse navigators address a much wider range of activities and treatment phases, from risk screening and genetic counseling to support group participation and survivorship. This is a much more advanced and nuanced discipline than inpatient care coordination. Different protocols and procedures are guided by complex care algorithms and tailored to different tumor types, based on extensive clinical research. Active management of common barriers to effective care — including financial, transportation, family and cultural issues — play a big role in oncology care coordination and have proven to deliver better outcomes.

4. Accreditation requires more care coordination than meaningful use compliance. Stage 3 meaningful use stage (MU3) is a big reason why EMR vendors are working to add care coordination modules. But MU3 sets a very low baseline, specifying that "patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for more than 15% of all unique patients."

Accrediting bodies have a higher bar. For example, the Commission on Cancer (CoC) dictates the following:
"A patient navigation process, driven by a community needs assessment, is established to address healthcare disparities and barriers to care for patients. Resources to address identified barriers may be provided either on-site or by referral to community-based or national organizations."

Other CoC standards have unique data and functionality requirements for ongoing barrier management, distress assessments, survivorship plans and multidisciplinary cancer conferences. Again, compared to the basic needs associated with brief episodes of inpatient, acute care, oncology care coordination is a long-term, multi-dimensional process.

5. Care coordination will be a cornerstone of future centers of excellence. It is no overstatement to say that using EMRs to coordinate oncology patients could compromise CoC accreditation. While it is true that not every specialty has such a "gold standard" accreditation, oncology offers a useful template for maturing care coordination capabilities in other specialties.

Therefore, we think service-line leaders in spine, orthopedics, behavioral health, bariatrics and other complex and chronic specialties should look at the oncology model and consider what measures will be enable them to identify as centers of excellence within their specialty. Can there be any doubt that timeliness of care and patient engagement — which effective, specialty-driven care coordination is proven to deliver —will eventually be key measures for all specialties?

6. Interoperability and data sharing are critical for clinical outcomes. Some of the motivation to use EMRs for care coordination is economic — that is, hospitals have made big investments in EMR systems naturally wish to consolidate as many activities as possible on those systems as possible to eliminate IT complexity. On paper, there may appear to be some financial upside. Reality is more complicated. Reduced IT maintenance fees must be balanced against the costs of patient outmigration, for instance, or low surgical conversion rates (to name just two areas where care coordination improves business outcomes).

The most compelling economic benefits from care coordination arise from complex specialties — oncology and spine chief among them. EMRs won't be ready to support these for many years to come, so specialty tools will be necessary to extend EMR's capabilities. The good news is that several specialty-specific tools are already quite mature.

7. The big challenge is around interoperability and data sharing. The American Medical Association has acknowledged the need for full EMR interoperability. Pressure is mounting on the big vendors to enable more data sharing.

But EMRs must do more than open themselves to passing patient records with other systems. They must figure out how data sharing can support a healthy ecosystem of purpose-built tools that are focused on improving business and clinical outcomes. The clear need to support care coordination outside the realm of single hospitals could be a great starting point.

Bottom line: EMRs have a role to play in care coordination
Generally speaking, our position is that the more care coordination the better. And many large hospitals clearly need it to improve utilization management and discharge planning capabilities within their own facilities. If EMR modules for care coordination help some hospitals instill basic care coordination where there is none today, that's good . As the market matures, stakeholders will naturally come to understand the different flavors or levels of care coordination.

Further, EMRs can and should play a big role in care coordination — especially in the realm of sharing data and integrating more smoothly. That's a sticky subject in the healthcare IT community, but one which is likely be to become less sticky as more stakeholders come to recognize the benefits of care coordination and the diverse toolsets necessary to deliver it effectively.

Gary M. Winzenread co-founded Cordata Healthcare Innovations in 2014 and serves as its president and chief executive officer. Used by more than 100 hospitals and healthcare organizations around the country, Cordata's technology solutions for specialty care coordination are designed for more effective patient management and improved clinical and business outcomes.

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