The Benefits of Interoperability Between Virtual and In-Person Care

By Matt Phillion

Poor electronic health record (EHR) interoperability can lead to challenges with both patient safety and cost of care. According to a study on the unintended consequences of national EHR adoption, poor interoperability can lead to medical errors, fragmentation of patient data, redundant testing, and an overall increase in costs.

Meanwhile, the increase in virtual care and telehealth has highlighted the need for better bidirectional sharing of clinical data between a patient’s regular care team and the patient’s virtual care providers, ensuring both have the patient’s full clinical history.

KeyCare, a virtual care company, has recognized that when health systems and virtual providers use the same EHR, they can minimize many of these challenges and simplify access to patient history.

“If you think about it, we’ve had some version of virtual care for 100 years. The reason it hasn’t picked up more is a combination of compensation, who’s paying for it, and cultural mores, but if you look at the places where there are financial incentives, you see a fair amount of virtual care,” says Lyle Berkowitz, MD, founder of KeyCare.

Cultural acceptance of virtual care has come a long way, he notes. “The use of video calls seemed like space-age science in the 1990s and became a regular occurrence with the advent of the iPhone®, and with it we saw the rise of third-party telehealth companies in the 2010s when you had enough bandwidth for streaming video on a regular basis,” says Berkowitz.

Prior to COVID-19, telehealth was just a drop in the overall bucket, with third-party vendors handling a few million visits per year, each in their own silo. However, with the pandemic, healthcare systems seemingly overnight had to convert the vast majority of their visits to virtual care, showing they could handle hundreds of millions of visits a year online, all within their own EHR systems.

“Suddenly doctors and healthcare systems recognized, we can do this—and more importantly, patients realized they could do this,” says Berkowitz. “The genie was out of the bottle. We’ve heard that patients want to go back to the office now, but by and large, studies show the vast majority of patients enjoy getting care online, especially routine care.”

Patients want ease of access, and if only a small percentage want to go back to every visit being in person, there’s suddenly a demand that’s not being met.

“Most health system doctors are ‘office-ologists.’ They’re optimized for the office: their staff, comfort level, compensation, and technology all exist there. But someone needs to take care of patients who want online care as well,” says Berkowitz. “And if we’re going to help health systems by providing them with providers who have an expertise in virtual care, aka virtualists, we’re going to be much better off using the same EHR system rather than using a completely separate one.”

This is where consistency in the EHR comes into play. “It cuts away all this friction around interoperability,” he says. “Epic has profound interoperability between two sites using Epic, so our providers see patient information sent from the health system in order to make better-quality decisions and ensure a more seamless patient experience. Meanwhile, our data is sent back to the health system so the patients have true longitudinal care. Everybody sees what’s going on.”

Reaching different types of stakeholders

Most health systems have three sets of constituents, Berkowitz says, and each group has different reactions to technology-enhanced service solutions.

“First are the IT and technology folks, and they immediately appreciate” when a solution that simplifies their job is offered, he says. From a data sharing and security of data perspective, these stakeholders are enthusiastic about a shared EHR option because it keeps things simpler for them. They don’t need to create new interfaces and can take care of existing interoperability. Data storage questions are easily answered, and there’s fewer hurdles to jump over.

“Think of it like two users working with Microsoft Word®,” explains Berkowitz. “I have mine fine-tuned to the way I use it, and you have yours set up differently, but if we trade documents, we’ll be able to see each other’s files,” he says. “It may not be using each other’s settings, but it will share the information.” Two organizations using Epic are in a similar situation when taking care of the same patient. Their settings might be different, but patients can book appointments and providers can share data between the two places.

The second constituent group is the vice presidents of telehealth or virtual care, a role that will vary from system to system. Some are embedded in the tech group, some are in strategy, and some are under clinical. “They want to see more telehealth, but their physicians may not want to do more telehealth visits, so this is a way to expand the front door with virtual staff augmentation. Every system wants a wider door because downstream revenue will increase,” says Berkowitz.

The third constituent group, often the hardest to reach, is the clinicians themselves. “I think there are three things you have to check off for those on the clinical side to adopt this,” says Berkowitz. “I call them the three Cs: clinically connected, compensation redesign, and culture/change management.”

A clinically connected solution means the health system providers feel comfortable that a virtual care partner is able to see their patients’ records and share them back, as bidirectional sharing can significantly improve patients’ quality of care.

Compensation redesign is more complex. “A major hurdle for health systems is how they navigate compensation plans based on a physician’s individual RVUs. If they go to a PCP and tell them all their easy patients will now be managed online by another group and they will only see complex patients in the office, they will rightfully be upset,” says Berkowitz. “But if you start paying physicians based on panel size management, they’ll welcome a virtual care team partner who can help them manage that panel online. They’re no longer in the mindset of ‘you are stealing my patients’ but rather that you’re helping them manage their population better. And as a result, they can earn a higher salary and decrease their patient burden in the office.”

Culture/change management also falls to the health system, because it has to commit to educating physicians, staff, and patients about the benefits of team-based care.

“Explain to patients how team-based care makes so much sense,” says Berkowitz. “Right now, patients might see their doctor a few times a year. With team-based care, patients would have a team dedicated to following them much more regularly, ensuring they adhere to certain activities and monitoring. But they would also know there’s a promise that if they have a more complex issue, the team will escalate it to their doctor to see them when needed.”

That’s what patients want, Berkowitz notes—convenient, efficient care for the easy stuff, and the knowledge that they can see their doctor in the office when they need to for more complex issues.

Top of the pyramid, top of license

Health systems often refer to the term “top of license,” and it’s possible to illustrate patient populations in a similar way by thinking of a pyramid—the upper part of that pyramid comprises the patients whom in-office physicians should be able to focus on. “Instead of seeing 20–25 patients a day with mixed levels of complexity, they could see far fewer who really need to be seen in person and they can have a material difference in meeting their needs,” he says.

Berkowitz himself is a primary care physician who changed careers because of this imbalance. He saw over 20 patients a day, but recognized that many were just seeking routine care and only a few truly needed a doctor’s full time and attention in the office.

“We don’t have a shortage of physicians, we have a shortage of efficiency,” he says.

He recommends taking a more rational approach to using these highly trained professionals: Use office-ologists for the smaller number of complex patients, and use virtualists for the larger number of routine care cases, managing large numbers of visits per day through efficiencies such as asynchronous care and automated tools.

“Virtualists are their own specialists, just like hospitalists. They love the high-volume, quick care and being able to take care of a lot of people. They’re attuned to that high-volume, lower-complexity type of care versus our office-ologists who are on the other end of the spectrum,” says Berkowitz.

There needs to be a realignment of how physicians are paid to make this work, though, because current practices don’t reward rebalancing the workload in this way.

“Some physicians prefer the office but don’t want to see 20 patients a day. If you went to them and said, ‘We’re going to increase your salary but decrease the number of patients you see by 50%,’ they’ll reasonably ask, ‘What’s the catch?’ The catch is we’re going to give you a team. That team will adhere to your rules,” says Berkowitz. “You’ll see fewer patients, but [you’ll] see the ones who really need to be seen in person. A lot of doctors are going to feel good about that.”

This rebalancing also helps avoid cognitive dissonance, Berkowitz says. It’s difficult to switch back and forth between in-person and virtual care, and enabling physicians to focus on one or the other could increase the quality of care they’re able to provide.

A more tech-enabled, team-based approach has the potential to make care more efficient, accessible, and affordable for everyone, Berkowitz says.

“The lower 50% of the population health pyramid only creates 5% of healthcare costs, but they really gum up the system,” says Berkowitz. “To me the goal is providing convenient, safe, affordable, high-quality care, and [to] reach a point where you’re able to call and address an urgent care issue or have a question answered when you need it almost immediately. And if you have a specialty issue, you should never have to wait more than a couple of days to at least start the process of care you need. If we use technologies and virtual care teams well, we truly will have less of an access issue than we do an efficiency issue.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.