Eastern Nephrology Associates is a nephrology practice in eastern North Carolina and northeastern South Carolina that comprises kidney specialists who deliver nephrology, kidney dialysis, kidney transplant and hypertension care in 14 offices, more than 40 dialysis centers and two vascular access centers.

THE PROBLEM

Eastern Nephrology's EHR was working well in the common fee-for-service reimbursement model. However, the nephrology practice began transitioning to value-based care in 2018.

One of the initial problems the practice encountered was the ability to identify patients who were assigned to value-based care programs at the point of care. There was no registry or label in the chart identifying whether they were in a value-based program. There were separate lists staff referenced to identify these patients, and it was substantially cumbersome for the providers and the management team.

"The second major problem for us was that data was siloed and hard to retrieve," said Dr. Carney Taylor, director of Eastern Nephrology. "Our office EHR did not communicate with the hospitals or dialysis units in a seamless way. It’s difficult to take care of patients effectively if you can’t see the entire continuum of their care.

"For instance, if there was a hospitalization, we had no visibility into it unless we printed the record and scanned it into the media tab of our EHR," he continued. "This required a lot of manual effort."

The next issue staff encountered was that even in their own EHR, the data was isolated in provider notes making it difficult for the care coordination team members to locate the information they needed. It made care coordination very difficult.

"As patients transition from chronic kidney disease to end stage kidney disease, there are numerous things that need to occur for the transition to be successful," Taylor explained. "Care coordination involving multiple team members is critical for achieving optimal patient outcomes during this transition, but our EHR did not have a common and easily accessible location for care coordination charting.

"Providers were entering some care coordination data into their notes, forcing our care coordinators to open up each individual encounter to identify the plan of care," he added. "In short, it was not a very efficient way to gain insight into a patient’s chronic kidney disease progression."

And finally, although staff could create standard reports in the EHR, the reports were not designed to help achieve performance goals in certain quality metrics that were being tracked in new value-based care agreements with government and private payers.

PROPOSAL

Acumen originally was created as a nephrology-specific EHR, so it was structured in a way that facilitated the nephrologists' workflow.

"Just before we looked at it, it was transitioned into the Epic platform, so we were enticed that we could get the benefits of Epic while maintaining a nephrology-centric focus," Taylor said. "We saw that Epic could help solve our issues around siloed records since many of the hospitals and other provider offices in our region were using their own instances of Epic.

"The interoperability of the EHR across the different healthcare settings was exciting," he continued. "Additionally, we liked the idea that Acumen would continue to focus on nephrology practices. The ability to have our EHR adapt to the way we need to take care of patients was critical."

Taylor also was optimistic that Acumen would continue to invest in functionality that would solve some of his value-based care challenges, like identifying patients who are in value-based programs at the point of care and developing better care coordination documentation tools.

MEETING THE CHALLENGE

Eastern Nephrology integrated with Acumen Epic Connect (electronic health record software for kidney physicians) in May 2020. Due to the pandemic, it was the first practice to transition to the platform in a virtual environment.

"The transition to any new EHR can be a traumatic experience for providers and physician practices and doing it during a pandemic added challenges; but today, our entire team uses Acumen daily," Taylor said. "It is essential to every operational activity, from patient care to the front desk, to revenue cycle management. It’s a complete solution for us.

"We started working with a value-based care management company, Interwell Health, in 2019," he continued. "Interwell Health then acquired Acumen in August 2022, and has continued to invest in improving how the EHR facilitates our value-based care services."

For example, embedded tools within Acumen help staff to perform and document chronic care management and transitional care management encounters. Staff also are starting to incorporate remote patient monitoring. The integration into the EHR via Acumen’s partnerships with RPM vendors will be critical, Taylor noted.

"The new EHR has now become an essential driver of our success in value-based care," he stated. "In effect, we were able to shift from the mindset of thinking of our EHR as a place to complete documentation and care for one patient to using it to not only record data, but to use it for analysis to drive actionable information and plans for care across all patients.

"The Acumen team continues to help train our providers and staff to get the most out of the system," he continued. "With the transition, we were able to make care coordination more efficient. Acumen’s intuitive design accelerated the process for the care coordination team, including our front desk staff, and it saves a lot of time for nephrologists."

Integrating with Acumen has afforded staff a full picture of where and when care was delivered for individual patient journeys, he added.

"Acumen also enables the discrete collection of data we need to create more detailed reports to also understand broader trends and issues within our patient populations," he said. "Having the ability to pull these reports instead of manually creating them also saves time and offers invaluable insights on our patients, collectively."

RESULTS

"Providers do not have any free time in their day – if an EHR makes their day easier, that's invaluable," Taylor said. "Their buy-in is much easier to obtain if the EHR makes the job of seeing a patient easier.

"There are a number of results that underscore what we’ve achieved," he continued. "One clear achievement is in optimal starts, which describes when a patient starts dialysis on a home modality, receives a preemptive transplant or begins in-center hemodialysis with a permanent access. Ultimately, an optimal start is more efficient, reduces hospitalizations, improves outcomes and lowers costs."

This year, the optimal start rate has been 90%. Previously, the optimal start was 40%.

"We’ve been able to significantly improve the care we provide our patients and our EHR certainly plays a role in it," he said. "If you look at transplant listings, that is the other area of success. Not everybody needs to be on dialysis, so our ability to refer patients and secure transplants has increased.

"I’m reminded of when one of the physicians in our group recently told me that our investment in value-based care had made it easier and more fulfilling for him to do his job," said Taylor. 

"He recalled meeting with a patient he had not seen in four months, and that he was pleasantly surprised that the patient had completed their kidney disease education, decided on a dialysis modality, had the appropriate testing and had already met with the surgeon to get a dialysis access placed."

Multiple complex steps had been accomplished by the care team through coordination and collaboration. The new EHR was essential in the process and the patient received a better outcome, he said.

ADVICE FOR OTHERS

"Strategic partnership between the physician practice and the EHR vendor is critical," Taylor advised. "In our case, value-based care is rapidly evolving, so what we need is a strategic partner who will evolve and learn with the programs you have in place.

"An EHR vendor needs to be focused on the things that are necessary for your practice to be successful," he continued. "A true partnership means they are talking to you constantly to understand what you as a physician are seeing in the field and bring solutions to address any issues from a technological perspective."

For example, the quality metrics for value-based care models often change and the EHR needs to be flexible and adaptable so that one can adjust their workflows to meet the new requirements, he added.

"If you have a static EHR that's not really focused on growing with your needs, it can be challenging for you to evolve," he said.

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