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Chronic care management model requires new EHR capabilities

The chronic care model requires interoperability and collaborative capabilities to coordinate a patient's care, but not all EHR systems include the necessary features.

For many hospitals and medical practices, the advent of accountable care organizations, federally qualified health...

centers and other collaborative care models is bringing about a strong push for an outcome-based payment model. This signals a necessary adjustment to the way physicians care for their patients. Patients with chronic conditions are now more likely to require far more interactions and different documentation than previously seen. While this may not be new to many, the fact remains that not all EHR vendors are fully prepared to offer the functionality needed to support a chronic care management model.

There are several new functionalities needed in an EHR system that physicians must be aware of to meet requirements under the new care models. The shift in paradigm will require them to have a much different experience and expectation of their EHR system. The options physicians use today may lack critical components that could impact the overall patient experience and their reimbursements. There are six critical questions EHR vendors must answer for physicians to ensure their readiness for the new chronic care management model.

1. Does your EHR support chronic care management?

For many primary care physicians treating patients with chronic disease, there are several capabilities that are a "must have" to document the care episode. Providers who participate in chronic care management (CCM) must use an EHR system that has the ability to track and document interactions with the patients. These may be face-to-face interactions, or general clinical staff time during or after working hours. Providers also need to have the ability to digitally communicate with their patients, manage medication adherence, medication reconciliation, treatment goals and documentation for billing purposes.

2. Can the EHR support physicians collaborating on patient care?

Physicians also need technology support for care coordination and management. Providers are required to work with other physicians as part of the patient's care team; this means the EHR being used needs to support capabilities such as data sharing, referral management and physician's communication mechanisms. Some EHR vendors offer add-ons or web portals that help support these requirements.

3. Is interoperability available?

To support care coordination, an EHR system must support data exchange. Most physicians are using certified EHR systems that are required to support interoperability. As a result, many physicians may already have access to this capability in their current EHR products. This functionality allows physicians to receive patients' clinical documentation when they visit other physicians and specialists.

4. Can your EHR maintain other non-clinical data for patients?

As providers become more involved in the comprehensive care of patients, additional aspects of the patient's record become more relevant. Social services, mental records, wearable device data and a number of additional data elements become more valuable and care providers need access to them. For physicians, these data elements are still decentralized and in many cases are not easily accessible. EHR options are moving toward delivering services that enable providers to become the central hub of data and all those external data can be imported into the system for providers to view and interact with. Whether a patient uses a fitness tracker or receives mental health services, all the data would be collected and available in one place.

5. Are patients able to leverage components of the EHR to be more engaged?

Patients with chronic illnesses require more engagement to ensure their health doesn't deteriorate. To support that, some EHR vendors have provided their clients with tools such as patient online portals for messaging, scheduling and personal health records. Fortunately, many of these capabilities are already included in many of today's EHR packages.

6. Are the reporting and analytics capabilities mature enough?

Analytics and reporting play a significant role in providing clinicians with the data needed for appropriate CCM. An EHR system must offer users the ability to access critical data about the patient's utilization, high-risk patients, patient profiles and subpopulations, as well as measure overall performance, process and outcomes.

The emphasis on time tracking, transition of care, and digital communication requires physicians to add new workflows and processes. While there are several supporting toolkits available online that can assist, organizations must consider the functionality available within their EHR product. This would determine whether or not they have the appropriate tools to succeed if the chronic care management model is an area they will actively participate in.

Next Steps

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This was last published in August 2016

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