How Interwell’s Epic EHR Powers Value-Based Outcomes for Payers and Providers

Acumen Epic Connect is the most-adopted nephrology specific electronic health record (EHR) in the country and a critical part of Interwell Health’s strategy to support patients with chronic kidney disease (CKD) with earlier interventions that slow progression. More than 70-percent of the Interwell Provider Network of over 1,800 nephrologists is using this customized instance of Epic.

Dr. Carney Taylor of Eastern Nephrology Associates in North Carolina and Dr. Tony Brown of Nephrology & Hypertension Associates of New Jersey discuss how they are using this Epic platform to drive population health and improvements in care for patients in value-based contracts.

Q: What was the reason your practice decided to move to Interwell’s Epic system?

CT: Our practice began transitioning to value-based care (VBC) in 2018. One of the initial and very fundamental challenges we faced was our inability, at the point of care, to easily and consistently signal to our providers and clinical team members that a patient was assigned to a VBC program. Additionally, in our previous EHR, population health data was limited as our perspective was siloed to individual patients and unique patient encounters which hindered us from recognizing system level opportunities for improvement. Being able to view a patient over the continuum of their healthcare journey and the outcomes of the entire population being managed requires a strategically aligned EHR and we found that in Interwell’s Epic system.

TB: Acumen Epic Connect gives us a wide and deep view of a patient’s medical history that often isn’t available on systems less tuned to value-based care. This allows providers to track patient health data over time, which can make it easier to monitor progress and identify potential gaps in care and safety concerns. The system also makes it easy to share treatment plans with patients, helping to engage them in managing their own care and increasing patient compliance with plans. This patient-centricity, enabled by the EHR, is a foundational pillar of value-based care and a key to unlocking its full benefits.

Q: How does Epic’s wide range of features like Care Everywhere support your efforts to improve outcomes for your patients?

CT: Our patients receive healthcare in multiple locations (hospitals, emergency rooms, dialysis units, and other outpatient clinics), and from a variety of providers outside of our own practice. Historically, records from these patient encounters were quarantined in isolated EHRs which can lead to poorly informed provider decision making and confused patients. In VBC arrangements, we are responsible for the entirety of our patient’s health, so it’s imperative that we have full visibility to all of their touchpoints with the healthcare system. Epic’s Care Everywhere provides us with a more complete view of our patient’s health care journey.

Additionally, we have been able to leverage Interwell’s Epic features such as care coordination documentation, provider alert messaging, and the patient portal to drive optimal outcomes at both the individual patient and population levels. Moving forward, we are excited about the deployment of remote patient monitoring and chronic care management through our integrated Interwell’s Epic system. Having an EHR that facilitates our ability to further “wrap our arms” around our patients in an efficient manner is so helpful.

TB: Personalized kidney disease care with individualized interventions requires managing clinical data sets across time and points of care. We need a holistic view of the records that "follow the patient," offering a comprehensive view of the patient's journey and support for the nephrologist. We need access to patient data captured wherever and whenever they have been cared for - be it the nephrology clinic, the patient's home, the dialysis unit, or a hospital.

Acumen Epic Connect is a powerful instrument for aligning incentives and driving practice changes that enable physicians to be successful in risk-bearing, pay-for-performance arrangements. It is helping us drive timely interventions, earlier identification of at-risk patients, help reduce readmissions, and much more. All of that adds up to better outcomes, lower costs, and more opportunities for physicians.

Q: How does Interwell’s Epic EHR support efforts to slow progression of kidney disease?

TB: Our EHR has become a valuable tool to help identify key moments in the transition of care and we plan to use new tools to better monitor a patient’s CKD progression. We know that prevention-based services such as immunizations and diagnostic screenings are critical for success in value-based contracts. The payment and incentive structures reward proactive, preventative care. And our Epic system can deliver timely reminders for screenings, co-morbid disease management, and other preventative care delivery.

When the entire care team is prompted to be more preventative-focused, it can lead to a practice-wide shift in thinking. Engaging the entire care team, including the front desk, care coordinators, nurses, and providers, is essential in moving the needle on the quality metrics required by VBC contracting. Acumen Epic is helping our practice decrease the overall cost of care by decreasing patients’ need for future unnecessary medical services.

CT: There are many results that underscore what we have achieved while using Interwell’s Epic. One clear achievement has been our performance in the CKCC quality metric referred to as “optimal starts.” The transition from CKD to ESKD is a treacherous time in a kidney patient’s life and it is our responsibility as their provider team to usher them through this transition “optimally” (defined as getting a pre-emptive kidney transplant, starting peritoneal dialysis, or hemodialysis with a fistula or graft). Achieving an “optimal start” requires intensive patient education and care coordination by our team. We rely heavily on Interwell’s Epic to connect all of the moving parts of the process. Not only is an “optimal start” better for the patient, it leads to reduced hospitalizations and lowers the overall medical costs, a critical ingredient for success in value-based arrangements. Our optimal start rate is now around 85 percent. Prior to our shift to value, it was below 50 percent. Interwell’s Epic has certainly played a significant role in facilitating the improvement.

Tony Brown, DO, MS, FASN is a nephrologist with Nephrology & Hypertension Associates of NJ and has more than 40 years of experience in the medical field. He is a member of the Interwell Health Provider Network and participates in government and private payer value-based care agreements.

Carney Taylor, MD, MBA is Co-President of Eastern Nephrology Associates and is a leading nephrologist with more than 20 years of clinical experience. He also serves as a board member for Interwell Health, participating in government and private payer agreements for value-based care.