Value-based care (VBC) has long been touted as the vehicle for chronic care management (CCM). If implemented, a diabetes patient could log into a system to know exactly when their next appointment is, their physicians could have access to all pertinent medical records, a pharmacist could know when to refill their prescriptions, and their family would know not to believe them when they say “just one piece of candy is fine.” Payment would be according to the quality of care instead of quantity, improving outcomes, and leading to a healthier population. Reality check: even though electronic health record (EHR) is almost universally implemented, it hasn’t lived up to expectations. 60-75% of healthcare providers are seeking VBC solutions outside of their current EHR. Why is this?

Industry Problems

Too Much Responsibility on Physicians

You go to the doctor expecting to see, well… the doctor. Only now, it’s the norm to spend almost all of your visit with a nurse then get some sign that translates to “you’re good to go” from the doctor on your way out. This is because physicians aren’t just physicians anymore — but project managers, administrators, IT — the list goes on. Doctors are spending an inordinate amount of time coordinating care rather than with their patients, and current EHR systems are putting too much responsibility on them. Today, doctors can expect to put in longer hours for lower pay — which is in part responsible for the sweeping epidemic labeled, “physician burnout.” The term refers to “a loss of enthusiasm for one’s work, a decline in satisfaction and joy, and an increase in detachment, emotional exhaustion, and cynicism.” According to the Mayo Clinic, 54.4% of surveyed physicians reported experiencing at least one symptom in 2014 — which is a significant jump from 45.5% in 2011. Physician Burnout Physician burnout has devastating consequences. For patients, this means poor quality of care. For doctors, consequences include:

  • Increased susceptibility to depression
  • Escalated suicide rates
  • Increased risk of drug and alcohol abuse

The introduction of EHRs was supposed to streamline the process, but in many ways, it clogged workflows. The systems available are heavily focused on the billing aspect of care rather than the patients — who should naturally be the focal point. Many doctors resort to partially using the EHR systems in place, then doing all the heavy lifting of patient coordination via phone calls and emails. This results in lost information, service duplication, and more. The complexity of typical EHR systems has only increased the likelihood of physician burnout.

Switching Payment Models is Difficult

In theory, EHRs encourage quality over quantity and cuts costs. Transitioning from fee-for-service to VBC presents many obstacles, but for the sake of clarity, we’ll focus on two:

  1. Implementing an EHR is a long process: How long the process takes is dependent on the organization, but for illustration let’s focus on hospitals. The process takes roughly a year and involves healthcare professionals at every level — administrative to physicians. After that year-long period, there is still plenty of work to be done. Developing a protocol for using the system and fixing bugs is an ongoing process that doesn’t stop after the launch date.
  2. Implementing a VBC system is complicated: Data is everywhere, but utilizing it effectively is a completely different challenge. The healthcare system in the United States is complex and fragmented. Therefore, ensuring all EHR systems can be fully integrated with one another and employ best practices is remarkably difficult. It doesn’t help that the United States doesn’t have a stringent set of standards for setting up VBC. On a scale of 1 to 5, with 5 being the highest, the Boston Consulting Group ranked the United States a 2 in this respect.

Clearing the hurdles for implementing a VBC system is only the beginning. Once the system is implemented, problems are likely to arise, such as:

  1. Privacy and threat of security breach: According to Don Jackson, Director of Threat Intelligence at PhishLabs, medical information is worth 10 to 20 times more on the black market than a personal credit card number. Implementing an EHR system poorly can make your healthcare organization a target for cyber attacks, setting you up for potential legal and financial troubles in the future.
  2. Risky financial investment: Completely changing the way your healthcare organization operates is scary — especially when the process is such a financial risk. In fact, 64% of healthcare executives who have EHRs say that it has failed to deliver the critical tools needed for VBC.

Ok, so the problem isn’t EHR — but in how it’s implemented. How can a system with so much promise turn into such a mess? The problem is a lack of interoperability. Interoperability is, “the extent to which systems and devices can exchange data, and interpret that shared data.”


Within the same healthcare system, everything is fine. The problems arise when different healthcare systems try and “talk” to each other. This is commonly thought of as one of the largest barriers to population health. According to a survey on private accountable care organizations, 85% of respondents have technologies that enable the accumulation and analysis of data from various systems within their healthcare organization, but 36% of them find it difficult to do the same with information from providers outside of their network. This is despite massive investments in these systems. Systems are often customized to a specific specialty making interoperability a distant goal. With this barrier, it’s impossible for a physician to know if their chronic care patient’s records are comprehensive. Without full knowledge of a population, performing data analysis on a patient population to find-out various information, such as what treatments are working or the cost of a patient with a certain chronic care condition, is near impossible.


The pitfalls of poorly implemented EHRs are clear. Let’s observe how EHRs affect specific chronic disease populations:

Example 1: Diabetes Population

As previously discussed, EHRs are great in theory — but when the systems can’t “talk” to each other, they are essentially useless. This problem is apparent with the management of the diabetes population, a fairly common chronic condition. From 2008 to 2014, the number of outpatient clinics with EHRs doubled from 42% to 83%. Logically, this should result in better communication between physicians and pharmacists — right? Wrong. Comparing the pre-EHR era to post, prescription errors stayed roughly the same (between 5% to 38%). Specifically, there is contradictory information within the same prescription 15-19% of the time, meaning pharmacists are often left struggling to clarify these errors on their own. To emphasize, this is not the fault of EHRs — only poorly executed setups. Successfully implemented systems would reduce errors in electronic prescriptions and increase the quality of communication between physicians and pharmacists.

Example 2: Asthma Population

EHRs are meant to centralize information for a streamlined and homogeneous approach to healthcare — most notable, chronic care. The keyword here is “meant” — in the UK there is no concrete definition for asthma, despite the near universal use of EHRs. The European Respiratory Journal published a study on the algorithms used in EHR systems to define asthma, the severity of the condition, and exacerbations. Just in the 113 articles analyzed, there were 66 different algorithms for defining asthma, 18 for defining severity, and 24 for exacerbations. 106 of the algorithms did not have statistical validity. The director of research and policy who also serves as the Deputy Chief Executive at Asthma UK, Samantha Walker, said “The data held on electronic health records has the potential to be of great value to asthma research, our overall understanding of asthma development, and development of new treatments. However, wide variations in how asthma is defined and recorded mean that these datasets are difficult to use for these purposes. As electronic health records become more widely used, it is vital to ensure all the information is defined and collected in a consistent manner so that we can have confidence in it. Until this happens we are missing opportunities to understand asthma fully and make improvements in asthma care.”

What to Look for in an Ideal Care Management Platform

Undelivered promises from EHR systems are the source of VBC problems. Instead of improving care quality and decreasing costs, EHR has created a cumbersome healthcare landscape. There are excellent EHR systems out there — but you must know what to look for.

Administration Capabilities

An ideal care management platform enables a program leader — a nurse coordinator for example — with the tools to do two things: set up permissions and controls to information so they can share what’s needed to deliver care in real-time, and delegate tasks to the appropriate individual. These two capabilities should be made possible with a user-friendly interface.

Interoperable Care Delivery

Your care management platform should be able to efficiently run complex sets of tasks — which is something a traditional EHR platform is unable to do. To do this effectively, you need a system that can collect relevant data on individuals then analyze that data to gain actionable insights. Meaning, the system should be able to use that data to help you pinpoint what is wrong with an individual, then provide follow-up steps to manage the problem, along with delegating those tasks to the correct individuals.

Comprehensive Data

This is not referring to data collected to tailor care for an individual, but the capability to collect data for back-end purposes — analyzing your diabetes population as a whole or to drive care quality, for example. The system should seamlessly combine automatically sourced data with manual data to deliver valuable insights.

Where Do You Find This?

Privis Health is a leading provider of digital health solutions that enable provider organizations to deliver efficient care to their patient population. Now, you can have a smooth transition to chronic care management programs that are inclusive of sociobehavioral, socioeconomic, and special needs of the patient and the population. The platform is a scalable, cloud-based solution that empowers healthcare providers to better manage the quality of care while achieving their operating and performance goals. Privis Health provides extensive quality measures and outcomes, the development of comparative performance information, and results-driven service models to improve system performance. The platform is capable of:

  • Managing transitions of care
  • Stratifying patient populations from aggregated data including EHRs, claims, registries, and EDWs
  • Identifying and managing high-risk patients
  • And more!

Instead of being bogged down by a manual system, you can rest assured your patients are receiving cost-effective care of the highest quality.

Download the PDF version of The Definitive Guide to Chronic Care Management today!

Experiencing any of these problems and want to see what the transition to a quality Chronic Care Management system looks like? Contact us today and we’d be happy to help.