As the leaders of patient care organizations move forward into the post-implementation phase around electronic health records (EHRs), they face a welter of challenges. Facing intensifying and accelerating policy, payment, business, operational, and clinical practice challenges, they are realizing that what has been called “EHR optimization” is really a very broad set of challenges around interoperability, information systems optimization, and IT strategy, organized around the need for patient care systems to become remarkably more efficient, cost-effective, and demonstrative of improved patient outcomes, and more clinician end-user-friendly, all with the ultimate aim of organization performance improvement.
One person who has spent a great deal of time helping healthcare IT leaders work through these issues is Rob Barras, a national partner, consulting, at The Advisory Board Company (Washington, D.C.), and responsible for leading pursuits on electronic health record (EHR) planning, optimization, implementation and go-live solutions. He is a 27-year veteran of health care IT, and has worked for years as a consultant, as well as at vendor company organizations. Recently, the Philadelphia-based Barras spoke with Editor-in-Chief Mark Hagland about the challenges around EHR optimization in the current policy and operational landscape of U.S. healthcare. Below are excerpts from that interview.
Looking at the present moment in evolution of the U.S. healthcare system, what is the landscape like right now for EHR optimization, from your perspective?
When I speak to audiences of Advisory Board Company member organizations, I’ve been sharing with them a summary presentation that focuses on five key challenges that healthcare IT leaders are facing in the next five years, broadly speaking. The first of the five, and the foremost among them, is the need for healthcare IT leaders to create value from the EHR investments that their organizations have made over the last few years. That sounds easy, and it’s something that everyone talks about; but prioritization becomes the real value. CIOs say, I’m being asked to do more with less, and how do I do that? And I say, prioritize—make sure you’re adding value to the organization. And the ones doing better are doing more with less; so that’s number one.
The next four key challenges easily fall under that first one. The second would be leveraging IT to enable value-based care—and that means pursuing things around risk identification and capture. In that context, healthcare IT leaders need to look at the HCC (hierarchical condition categories) model, as articulated by CMS [the federal Centers for Medicare and Medicaid Services] to determine the complexity of a patient population. Two years ago, I would have said that 80 percent of CIOs, or really anyone—COOs, CFOs—had very little concept of HCC and risk-adjusted reimbursement; but that proportion has flipped now. And you’re starting to see the vendors get more involved in that work. But it’s very complex, and risky if you’re not documenting appropriately. But over the next five years, we’ll make progress in that important area.
The third key challenge is a set of challenges around interoperability. Looking at where we’ve been in healthcare and where we need to get to, it really is unbelievable that we’ve still got such a low proportion of interoperability; but progress is happening. The fourth key challenge is the ever-changing provider landscape. The acceleration of mergers and acquisitions reinforces care variation and increases cost. So we’re going to have to manage that and help standardize and decrease costs. And the fifth key challenge would be creating value from data. I sometimes hesitate to use the word “analytics,” because it’s over-used. Really, “analytics” just means making use of the data that is there or might be there. We need to move towards predictive analytics for risk assessment and management of populations.
From what we’re hearing from CIOs, CMIOs, and healthcare IT leaders across the country, healthcare IT leaders are getting stuck trying to put analytics solutions on top of EHRs, with regard to interoperability and ease of use.
I absolutely agree. And in that context, I recommend to everyone that they begin with data governance. Who are the operational stakeholders for each piece of data? How do we identify terms? How do we standardize terms internally? Length of stay may mean different things in different service areas. So you’ll need to develop a data dictionary. Go through that governance process first, and develop what we call an analytics roadmap. So now, let’s create that roadmap of what the requirements are in each area—everything from what dashboards we need in each clinical area, to what the dashboards are that are needed to manage specific at-risk populations. And ask, is my EHR vendor going to provide everything I need to manage all of this, or do I need another tool? And the thing is, there’s so much noise out there at HIMSS [the annual HIMSS Conference, sponsored by the Chicago-based Healthcare Information and Management Systems Society], and everywhere.
What CIOs and other healthcare IT leaders are telling us is that they’re having to do a lot of customization, in order to make their analytics solutions work for them.
I completely agree. Regardless of what the vendors are saying, there is not an easy, off-the-shelf solution out there. And very often, much of the work needs to be done by the health systems themselves; and they’re just incapable of getting there, for some very good reasons. A, it’s very complex; and B, we’re in the middle of probably the greatest change this industry has seen, and trying to narrow down what your data requirements will be five years from now, is very difficult. And data governance is one thing. In terms of the roadmap, our recommendation often is, just wait: you’re doing OK managing spreadsheets—and right now, if you can’t articulate what your requirements will be a year from now, just wait; and that’s OK.
In other words, what you’re saying is, don’t try to boil the ocean; instead, start with good use cases and build from those, correct?
Yes, I agree completely. It’s exactly why we recommend to many of our members to just hold off [on purchasing new commercial analytics solutions]. There’s just so much [business and policy] activity right now. I mean, there are some things that won’t change, but from a legislative standpoint, we know where we’re going. And regardless of where we end up legislatively, the model is moving towards value. That we do know. But really, that policy shift is driving market activity, which is driving the inability for many organizations to determine what they should do. For organizational leaders who believe that their organizations are stable—they’ve already merged with the organization across town, for example—if they feel stable, now you’ve got a better feel for what the requirements are [in terms of their organizations’ needs for analytics capabilities]. We’ve decided we’re going to be really, really good at these five areas, and we’re going to have a center of excellence around this particular area. Then that gives you the clarity.
How should CIOs and CMIOs look at the horizon around this subject, projecting out, five years from now?
This is probably more of my background speaking more than anything else. I spent the first seven or eight years of my career on interoperability. That really is the greatest challenge. And over the next five years, that’s where we need to make the biggest leaps. And I don’t know whether we’ll need government intervention—in fact, I do think we will need a meaningful use for interoperability. We really need to get that intervention. The challenge is that we still largely live in a proprietary, fee-for-service-based world, and we’re hoarding data and information; and we need a signal to tell us to stop hoarding the data. But if I were a CIO, I would be more focused on that. And ensuring that I have the greatest percentage of a patient’s record, electronically, access to it, that would be my focus. That’s more of my background, back in the CHINs [community health information networks, the forerunners of today’s health information exchanges, or HIEs] era.
Is there anything else you’d like to add?
Really, I think that there’s a lot to focus on there with regard to those five key challenges. I spend an entire 90-minute presentation on those key challenges, to our members, in member presentations. So that’s enough to work on, right? There’s a lot of stuff to do. The prioritization thing is really a big challenge for health systems. So my final advice would be to do what’s important, and forget the rest.