As value-based payment plays an increasingly prominent role in health care, it is affecting what care is provided and how it is delivered, according to speakers at the ECRI Institute 24th annual conference held in Washington, D.C. Thus, new value-based rules, processes, and programs can have a major impact on workload, workflow, and the use of workarounds (temporary fixes that may bypass protocols for efficiency), and they may create barriers in daily practice.
The ECRI Institute is a nonprofit organization whose mission is to use the discipline of applied scientific research to improve patient care. The conference was cosponsored and planned by the U.S. Department of Veterans Affairs; Kaiser Permanente; the Patient-Centered Outcomes Research Institute; AcademyHealth; the Bipartisan Policy Center; the Council of Medical Specialty Societies; Georgetown University, where the conference was held; the Penn Leonard Davis Institute of Health Economics; and Penn Medicine, the University of Pennsylvania Health System.
Improving Oncology Care
The issues of workload, workflow, and workarounds are especially important in oncology because the field is so complex and its science base is evolving so rapidly, said panelist Richard L. Schilsky, MD, FACP, FASCO, FSCT, Senior Vice President and Chief Medical Officer of ASCO. "We work at a time of rapidly changing clinical science," said Schilsky. "Oncologists manage very complex patients with life-threatening conditions; typically [patients] see multiple specialists," he added.
Oncologists may see patients in multiple venues, he noted, including physicians' offices and hospitals. Unfortunately, the patient's electronic health record (EHR)-a key tool of value-based care-may not be interoperable and shared among these various treatment venues, hampering efficient care decisions. For example, noted Schilsky, sometimes information has to be faxed from one center to another-increasing the workload and interfering with workflow. In addition, because cancer care is delivered by a team, many professionals in addition to oncologists may contribute to the patient's EHR, including oncology nurses, pharmacists, and geneticists, adding to EHR complexity and lack of coordination.
Clinical pathways, also a key tool of value-based care, are becoming pervasive in oncology, and increasingly they are being incorporated into EHRs, Schilsky stated. But, he stressed they can create problems for oncologists in a field moving toward personalization of treatment based on the individuality of the patient's tumor. "There is a tension between the payer focus on minimizing variation in care and where the science is," said Schilsky. "Oncologists feel a little bit caught in the middle."
For example, a clinical pathway may not allow advancement to the next step unless specific information is provided-which the oncologist may not have. What the oncologist really wants to know is whether the patient has localized, potentially curable cancer or metastatic cancer that is likely incurable, he explained.
ASCO guidelines generally represent deep analyses of a clinical problem and are very different from a clinical pathway. Schilsky sees ASCO moving away from these "deep-dive" analyses and more toward short guidance statements to be used in a timely fashion at a patient visit. "We are thinking hard about providing guidance to doctors at the point of care," he noted. For example, such guidance might be used to determine which molecular testing would be best for a given patient. He said ASCO is now grappling with the best way technologically to deliver that point-of-care guidance, perhaps through an EHR message alert.
Analyzing Workarounds
Workarounds were much discussed at the ECRI conference. They are inevitable given the stresses of real-world practice, suggested panelist Steven J. Stack, MD, an emergency physician and Past President of the American Medical Association (AMA). "Work as it is done is not the same as it is imagined," said Stack, who has served as an advisor to the federal Office of the National Coordinator for Health Information Technology. He pointed out that there are many interruptions in clinical practice, equipment goes down, and there are drug shortages. Stack said that, while physicians have an obligation to improve the health system, "arbitrarily rigid" quality measures that do not keep up with changing science are not helpful and can be barriers; they need to evolve with time.
"What's celebrated is getting the job done," said panelist John Glaser, PhD, Senior Vice President for Population Health at Cerner Corp. A workaround "can become the new normal...workarounds make us safer overall, not less safe; people are doing workarounds to deliver care faster and better," Glaser noted. But, he said the term "workaround" has a negative connotation and he proposed using another term, such as "transition resilient adoption."
If a workaround has a bad result, such as an adverse event that compromises patient safety, that exacerbates the negative connotation of the term, said panelist Rollin (Terry) Fairbanks, MD, MS, FACEP, Founding Director of the National Center for Human Factors in Healthcare, Assistant Vice President for Ambulatory Quality and Safety at MedStar Health, and Associate Professor of Emergency Medicine at Georgetown University. "Some workarounds are not safe, but some we can learn from to improve the system," said Fairbanks.
"Culture is important," and the culture needs to be one where nurses feel safe with workarounds, said panelist Patricia P. Sengstack, DNP, RN-BC, FAAN, Nursing Informatics Executive at Vanderbilt University Medical Center and Associate Professor at Vanderbilt University School of Nursing, Nashville, Tenn. She suggested that there needs to be an organizational structure to evaluate workarounds and improve the system.
Schilsky said workarounds may recognize the most efficient way to accomplish a goal, thus becoming a creative solution for a systems problem that needs to be solved.
Information Workflow
Heavy reliance on the EHR in value-based care was also much discussed at the ECRI conference. The EHR has value in allowing health professionals to see a patient's continuum of care, said panelist Patrick J. Brennan, MD, Chief Medical Officer and Senior Vice President of the University of Pennsylvania Health System, Philadelphia. But the downside, he said, is that more time is spent on the computer, often at home after hours. In addition, he noted, physicians may not fully know how to use the EHR and may inadvertently give passwords away, for example.
Brennan said his colleagues have also reported the following problems with EHRs to him: difficulty of use, leading to "navigational overload" and lack of coordination among professionals writing notes in the EHR (such as the attending physician and a fellow), especially in an academic setting.
When there is an EHR glitch, such as a mismatch with laboratory transmission of results and a patient's Social Security number, there can be a time delay in workflow that could harm a patient who needs a transfusion, for example, said panel moderator Ronni P. Solomon, JD, Executive Vice President and General Counsel of the ECRI Institute. She noted that a mismatch in billing information can also slow down workflow patterns.
More on MACRA
Speakers also discussed implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). As previously reported in Oncology Times, MACRA moves Medicare payment from a volume-based reimbursement system to a value-based system focused on outcomes, and encourages alternative payment models (APMs). "Let's not pretend that this isn't burdensome to providers," said panelist Kate Goodrich, MD, Director of the Center for Clinical Standards and Quality and Chief Medical Officer of the Center for Medicare & Medicaid Services (CMS). "The goal of MACRA is to change behavior," she noted, stating that CMS is well aware that there is a wide variation in the scope of U.S. practices and the way U.S. physicians practice medicine. She said CMS wants to ease administrative burdens on clinicians as they make the transition into value-based Medicare reimbursement.
ASCO and certain specialty societies have voiced opposition to a MACRA provision on drug reimbursement. CMS recently released a final rule that makes Part B drug reimbursement subject to Merit-Based Incentive Payment System (MIPS) adjustments. ASCO has stated that this would significantly distort the magnitude of penalties and bonuses physicians would receive far beyond what Congress intended when drafting MACRA. In a resolution to the AMA House of Delegates, ASCO called on the AMA to continue to work with ASCO and other specialty groups to advocate against applying the MIPS adjustment to Part B drugs. The resolution is co-sponsored by the American College of Rheumatology, American Academy of Ophthalmology, and American Academy of Neurology.
Goodrich said she is aware that MACRA is a complex set of programs that do not please all. But, "we want to allow for flexibility at CMS; the tradeoff is complexity." She noted that in its final rule CMS exempted more clinicians in small practices from MACRA. Goodrich said CMS recognizes that "there are not enough APMs out there," especially for small rural practices and specialists. "There are some who feel we're moving too fast and some who feel we're moving too slowly," noted Goodrich of MACRA.
Schilsky pointed out that there are certain levers to change physician behavior: reimbursement, regulation, certification, licensure, and sometimes litigation. "I believe doctors want to do the right thing," he said, but incentives for change are limited and physicians' time is limited. Asked by Oncology Times if he believes the levers he cited are working effectively, he answered, "Doctors will do what they need to do to stay in practice."
Peggy Eastman is a contributing writer.