How EHR Integrations Can Tailor Patient Outreach for Value-Based Care

In the shift toward value-based care, many healthcare organizations are looking for EHR integrations to support population health initiatives and optimize patient outreach.

Take Henry Community Health (HCH), for example.

Executives of the east-central Indiana health system looked to a health IT implementation to streamline what was previously a manual, time-consuming patient outreach strategy.

"We had been trying to reach out to patients to close gaps and do campaigns for things like colonoscopies or mammographies, but it took a lot of manual work," Mike Spencer, chief information officer at HCH, told EHRIntelligence in an interview.

Closing care gaps is paramount for value-based care delivery, as getting patients in for preventive services is a key clinical quality measure. This comes as the industry shifts toward risk-based payment models.

"In value-based care, if you meet certain measures, you could get bonus pays, but all payers are moving towards risk, meaning if you don't make certain measures, they will withhold money," Sherry Willis, director of information systems at HCH, said. "It's a different way of contracting, and we knew that the payers were going to be moving us there."

Healthcare organizations are better-positioned to hit those quality measures—and succeed in risk-based contracting—when they can engage patients in care and close those care gaps.

Previously, HCH staff would go through the EHR to create patient lists for preventative health campaigns, such as colonoscopy screenings. Then, staff would upload the lists and send them to a third-party vendor that would conduct patient outreach to schedule appointments for the health system.

But that process can be onerous and could contribute to the nation’s mounting clinician burnout problem.

"We needed a system that would better help us manage those populations, give us visibility to how we're doing on the measures, and have a way of getting good lists of patients for outreach," Willis said.

HCH worked with Oracle Cerner to enhance interoperability across the health system and support population health through the vendor's customer relationship management (CRM) solution, HealtheCRM.

The EHR vendor's CRM tool conducts automatic patient outreach based on information from HealtheIntent, a data and insights platform that aggregates EHR data with payer files to create longitudinal patient health records.

"It takes the information that HealtheIntent has gathered about your populations and whether those patients have met measures, and it feeds all that to CRM automatically," Willis explained.

"For example, one of the measures we have to track for the ACO is breast cancer screening," she said. "HealtheIntent already knows the list of patients that are due for a mammogram, and it feeds that information to HealtheCRM."

Then, HCH can create and disseminate outreach campaigns through the CRM tool in real time.

If patientsqualify for screening, either by age or because they are overdue, the system automatically adds them to the campaign for text and email outreach.

"It's always looking for more patients that qualify," she said. "I don't have to keep rerunning lists and doing another campaign today that's not 100 percent accurate as of tomorrow because I could have new people qualify."

"The old way we did it was more like a snapshot in time," Willis noted. "By the time we were done with that campaign, probably 100 more people should have been called. HealtheCRM is always looking for more patients daily who qualify and need outreach, and I don't have to babysit it."

Additionally, Spencer pointed out that since the system is constantly running and contacting patients, clinicians have steadier patient loads.

"We would have surges where we had all these people we had to schedule for mammographies or colonoscopies," he said. "Now, we can give the clinician a more consistent patient load so that it's easier for us but also more convenient for the patient."

After integrating the CRM tool, the EHR vendor assisted HCH in setting up five initial campaigns.

"We pulled in quite a few different groups of people in different areas to brainstorm what would help us the most," Willis said.

The first CRM campaigns were for breast and colorectal cancer screenings, two outreach initiatives HCH had previously conducted manually.

"These are not only ACO measures that we were tracking, but they're also service lines that, if we got people in, would help us increase revenue," Willis explained.

Next, HCH decided to focus a campaign on diabetes since the disease affects a large portion of its population.

"We run a campaign where if a patient's A1C is out of range, it sends the patient an email that links them to an educational program they can watch about their diabetes," Willis said. "We also send information on our diabetic educator program that encourages them to get scheduled to meet with our educators to get further help managing that disease."

For the fourth campaign, HCH looked at readmissions due to COPD, CHS, pneumonia, stroke, and joint replacements.

Managing readmissions is critical to value-based care. Research from the Agency for Healthcare Research and Quality (AHRQ) shows that hospital readmission costs were higher than initial admission costs for about two-thirds of common diagnoses in 2016.

"We have difficulty managing our readmissions here," Willis said. "If anyone discharges with one of those disease types or if they have had one of those surgeries, then it sends an email or a text to them within a couple of days with their follow-up appointment date and time and reminds them that they need to go to that follow-up appointment and make sure that they've got a support system in place."

"On the back end, if they do not go to that follow-up appointment, they fall onto a list so that we can reach out to those patients, see why they no-showed or canceled, and see if we can't get them rescheduled," she said.

The fifth campaign was a marketing campaign for orthopedic patients.

"We had won a distinction award for some of our ortho surgeries, so we did a marketing campaign letting people know that if they are having any issues with joints of any kind, we are great in that area," Willis explained.

HCH has since built its own campaigns. For example, the health system recently did an outreach blast to inform people about an educational session on pain and pain management.

"We had two sessions, one in an area outside our county and another in our county," Willis said. "We created two separate lists based on zip codes, and we pushed the appropriate email to each of those lists so that they got the email for the session closest to them," Willis said.

HCH also used the CRM tool to send out its community health needs assessment and saw a significant uptick in responses compared to its previous strategy of mailing paper surveys to patients.  

"The last time we did a community health needs assessment three years ago, it was mailed to patients, and we got 300 responses," Willis said. "This time, we used HealtheCRM and got over 2,000 responses, so our data on that assessment should be more accurate than it's been historically."

HCH plans to continue adding outreach campaigns to support value-based care delivery, including one for patients due for their Medicare annual wellness visit.