By James E. Grue, OD,
and Ronald P. Snyder, OD, FAAO
May 6, 2020
The current health-care crisis is delivering an important lesson to the country about the importance of transforming healthcare to an outcome-based system. This lesson also demonstrates the adverse results of not doing so.
The Affordable Care Act was enacted to stimulate the transition of healthcare from fee-for-service to an outcome-based system. Although there are some instances where that has actually happened, as a whole, the health-care system and providers have been resistant to making that transformation.
Here are key lessons the COVID-19 crisis has taught us about the hazards of not having an outcome-based health-care system:
We must have data from comprehensive clinical outcomes
Most of us know the statistics on the number of people in our state who have tested positive for Covid-19 and the number who have been admitted to the hospital and died the previous day from the virus. Those statistics are known as clinical outcomes. In relation to this crisis, they are the clinical outcome measures showing how effectively sheltering-in-place recommendations are working.
These clinical outcomes are easy to obtain as the mechanism to collect this data already exists and is used on a regular basis throughout the health-care system. Without this data, there would be no way to determine the effectiveness of the shelter-in-place orders. Although this is valuable data, it doesn’t tell the whole story. Everyday, on virtually every network, news reporters, and the public around the country are asking “How many people are at home with symptoms that are suspicious of Covid-19, and how severe are their symptoms?” The answer in every instance is: “We don’t know.”
But at the same time, everyone understands that without knowing that information, we are missing critical data that is needed to make important decisions.
What is most disturbing, and demonstrates the failure of providers to utilize the features that are built into our electronic health records, is that, the mechanism to easily collect this information already exists in every certified EHR. Every “certified” EHR is required to have a patient portal to give patients the ability to communicate with their providers and to let them know what is happening to them.
Those same certified EHRs also are required to have the ability to report data to registries. The problem is two-fold: 1) EHR vendors have implemented only the minimum required standards to obtain certification; 2) Providers have not used these features to any great extent. Although these features are included in every EHR, they haven’t been refined, through use, to be able to capture and process this vital data.
If these features had been implemented correctly and used by providers, then every hospital-based EHR would provide a method for patients to log in and fill out a standardized form of symptoms. The results from those forms could be automatically forwarded to a registry which would extract and analyze the data and make it available to local providers, as well as state and national officials. On their daily TV updates, the politicians and administrators would simply have to remind patients to log into their patient portal to report their current symptoms.
Having this data would significantly affect how this crisis is being managed.
Valid outcome data changes performance
It is obvious that in this crisis, as the number of hospital admissions and deaths increases, the compliance with orders to shelter-in-place also increases. Recommendations to shelter-in-place are more effective if those recommendations are backed up by outcomes data.
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The public, politicians, administrators and providers are gaining first-hand lessons of the power of outcomes data in this crisis. These lessons are going to result in many changes in our health-care system that will help prevent future pandemics from being as severe. It will also result in everyone taking a much closer look at how outcomes affect the regular delivery of care even when there is no crisis. As providers and patients, we are learning that we can deliver a completely different level of care when we have outcomes data to use in our decision making.
Outcome data directly affects the delivery of care
An outcome-based registry currently exists which provides outcomes data to eyecare providers. Let’s look at a few examples of outcome studies in eyecare that are already in progress. The question to ask is whether you, if this data was available to your practice, would make different decisions as to how you provide care to your patients?
1) Myopia management mystery
a. Does it make sense that many eyecare providers don’t do any myopia management whereas others specialize in myopia management? We even have a recently approved soft contact lens for the management of myopia.
b. The answers to this mystery already exist in the data in our EHR as every one of us has years of data to show exactly how myopia progresses with each patient and each population of patients.
c. The use of a clinical outcome registry unlocks that information and presents it in a way that makes it clear that we have different populations of patients that progress differently. A registry lets us compare those populations based on how we have decided to manage those patients with similar populations that were managed differently in other practices. If you haven’t been doing any myopia management, you can easily see the difference in outcomes from comparison groups that have been managing the condition by various techniques.
d. The important thing to recognize is that you don’t have to do anything other than utilize a registry to access this important information. The data is extracted automatically from the database in your EHR and sent to the registry. All you have to do is to log into the registry to see your analyzed data. You will have exclusive access to your own individual data. No one else will be able to see your results. Also, you will have access to multiple comparison groups of congregated data from which you can compare your outcomes.
e. The AOA recently released evidence-based clinical guidelines for diabetes management which significantly changes the role of the eyecare practitioner in the management of diabetes. One of the evidence-based studies sited in the guideline indicates that if the average A1c is reduced from 9 to 7 over a 10-year time period, the amount of retinopathy is reduced by as much as 76 percent in some populations.
f. As a patient, would you rather go to an eyecare provider who educates you about those potential outcomes and works with a care team to help you reduce your A1c to help lower your risk of having to have injections in your eyes? Or, would you prefer to go to an eyecare practitioner who simply says, “You don’t have any retinopathy, come back next year and we will check you again.”?
g. As a payer, would you rather have providers on your panel that are helping patients reduce their risk of developing retinopathy and are potentially decreasing the cost they are going to have to pay for care, or have providers that are simply allowing the retinopathy to develop and view their role as simply detecting and referring it for treatment?
h. Eyecare providers that are using outcome registries are able to track the effectiveness of their efforts in lowering A1c. Interestingly, evidence is mounting that eyecare providers may be the most effective providers on the patient’s care team in helping the patient lower their A1c.
i. Payers are interested in outcome measures too. They are willing to create alternate payment systems to incentivize providers to follow the AOA guidelines, but they need to first see the outcome data. This could have a huge return on investment for the payers while potentially significantly increasing income to providers.
2) Utilization of specialty IOLs during cataract surgery
a. Clinical registries are starting to show a huge variation in the utilization of specialty IOLs by cataract surgeons. Utilization varies from approximately 7 percent to almost 90 percent. If our goal is to deliver the best care option to every patient, it doesn’t seem to make sense that there is that much variation.
b. Let’s look at what is emerging from outcome analytics. With lower-to-medium income patients, those that agree to specialty IOLs appears to go down compared to higher-income patients.
c. It makes sense to jump to the conclusion that this is simply the function of economics. The outcome analytics might be suggesting something totally different. Instead of it being purely a financial issue, it might actually be more of a process issue. Patients who have limited monetary resources may be able to take advantage of specialty IOL options if they have more time to plan for the additional expense.
The process could be as simple as giving the patient a pamphlet, at the earliest onset of cataracts or during the progression of the cataract that explains the IOL options. In traditional care, even if you did initiate these process changes, you wouldn’t know what affect they were having. If you are using a clinical outcomes registry, with no additional effort, you would know exactly how effective this change in process was in affecting outcomes.
3) Attrition rate is an outcomes measure
a. Most providers know how many new patients they see each month. Few know how many patients they actually lose each month.
b. The use of an outcome’s registry provides accurate data on how many patients do not return for care and the data is provided by diagnosis. Seeing that your attrition rate on presbyopes may be completely different than it is with patients that you have diagnosed with cataracts, for example, allows you to identify and correct the issues that result in patient attrition. Knowing this information may be one of the most effective ways you can bring your practice to the next level of success.
Subscribing to an outcomes-based registry is inexpensive, requires virtually no additional effort or work on the part of providers or staff. A registry can provide insights into the care we delivery that are simply impossible to identify otherwise. Almost any progressive or chronic condition in eyecare can be looked at in a similar manner to the conditions listed above. Our EHRs already contain data for dry eye, AMD, glaucoma and refractive errors, which contain insights that only become obvious when we analyze the data.
The Covid-19 crisis has shown us, as a country, the importance of outcomes data and has helped us understand how to use that data to better manage a pandemic. Eyecare providers can use these same lessons to realize that we can do so much more when we apply an outcomes approach to the care we deliver.
Editor’s Note: There are three registries available to eyecare practitioners at the current time. Two of these registries are the AOA MORE registry and the American Academy of Ophthalmology’s registry, IRIS. Both of these registries are currently predominately used for reporting quality measures associated with Meaningful Use and MIPS. They are both working toward providing clinical outcome data as well. The third, HealthCare Registries, started as a clinical outcomes registry exclusively for eyecare and has expanded to be able to share clinical data with other registries and to participate in outcome studies that combine data from across medicine.
James E. Grue, OD, is a health-care reform speaker and consultant. To contact him: JimGrue@HealthCareRegistries.com