Fragmented Care: Gaps in Patient Data Sharing

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Modern Healthcare Print Version

February 21, 2014

In 2011, Henry Ford Health System signed an affiliation agreement with CVS Caremark Corp.'s MinuteClinic unit under which Henry Ford doctors act as MinuteClinic medical directors and do consulting for the retailers' patients. Henry Ford also refers its own patients to MinuteClinic locations for night and weekend primary care.

But the big Detroit-based health system has not yet connected its electronic health record (EHR) system to the pharmacy chain's in-store clinics because it hasn't completed its own EHR installation. Henry Ford patients treated at a MinuteClinic location have their records faxed to primary providers. Henry Ford is using Epic as its EHR vendor while CVS has a proprietary EHR.

Retail clinic operators such as CVS are rapidly expanding into the estimated $5 billion market for simple primary-care services. But their growing presence and popularity is raising concerns about further fragmentation of medical care, even as momentum grows for tighter coordination across the continuum of care.

Critics contend that continuity of care can be disrupted when patients visit a walk-in clinic rather than their regular primary-care physician or clinic. In a 2012 study published in the Journal of General Internal Medicine, patients were less likely to return to primary-care doctors to treat simple acute conditions after visiting a retail clinic, though the same study found no evidence that patients sought less preventive care or disease management.

In addition, retail clinic visits may go unreported to primary-care doctors, creating a gap in patients' medical histories. Patients who visit retail clinics may be due for screenings or more complex care that can get missed in retail settings, where the scope of services is limited.

Compounding these concerns is the fledgling state of efforts to share patient records electronically between retail clinics and traditional providers such as physician offices, hospital clinics and long-term care facilities. Major retail clinic operators CVS and Walgreen Co.-which have announced plans to increase their locations this year by 19% and 25%, respectively-have installed electronic health records, though their systems are proprietary.

"We have this interesting disconnect," said Dr. Ateev Mehrotra, an associate professor in the Department of Health Care Policy at Harvard Medical School, who studies retail clinics. "As a physician, I hear it all the time: 'Don't you guys talk to each other?' "

Advocates of retail clinics hope these clinics will expand primary-care access and help reduce unnecessary hospital emergency department visits that undermine efforts to reduce healthcare spending. These clinics, often located in pharmacies and other retail settings, are typically staffed by nurses, nurse practitioners or physician assistants. Patients who find it difficult to reach a primary-care physician or find primary-care clinic hours too limited may turn to retail clinics, most notably during evenings and weekends, proponents say. Such clinics also may mitigate the national primary-care physician shortage. Wait times for family practice appointments range from five to 46 days, on average, according to a recent 15-city survey by physician recruiting firm Merritt Hawkins.

According to the Convenient Care Association, there are more than 1,400 retail clinics nationally, with that number expected to rise to 3,000 by 2016.

Healthcare providers participating in accountable care organizations and capitated managed-care arrangements have financial reasons to work closely with retail clinics because they are incentivized to have their patients avoid expensive hospital admissions and ED visits. And some employers and insurers, such as Marriott and Blue Cross and Blue Shield of Minnesota, also are working with retail clinics by reducing their plan members' out-of-pocket costs when they visit these clinics because they see the potential for cost savings.

"This can be an important way for people to get the healthcare that they need," said Dr. Charles Kennedy, CEO of Aetna Accountable Care Solutions.

But patient data-sharing issues remain. While Henry Ford hasn't yet connected its EHR system with CVS' MinuteClinic unit, the final phase of its Epic EHR installation is expected to be completed this year, which should allow the health system to make the connection, said Paul Szilagyi, the health system's vice president of primary care and medical centers.

CVS says it has signed 30 such affiliation agreements with health systems, including the Cleveland Clinic. CVS contracted with Surescripts to connect its proprietary EHR system with the EHRs of the health systems with which it has signed affiliation agreements, said Dr. Nancy Gagliano, chief medical officer for CVS' MinuteClinic unit. It has not yet announced a vendor for its full EHR implementation, but entered a pilot in 2012 with Allscripts. Where no electronic connection is yet possible, the CVS clinics fax or mail records to patients' primary-care providers.

Half of the provider systems affiliated with CVS already are connected, to varying degrees, Gagliano said. Progress has been slowed by necessary work with attorneys to ensure compliance with federal health privacy regulations.

CVS is also working with state health information exchanges, which seek to build statewide health IT connections. But data transferred across the exchanges can be limited, Gagliano said.

Electronic record-sharing connections between all providers are increasingly important as health systems enter into contracts with insurers that reward providers that coordinate care to lower costs and improve quality, such as accountable care.

CVS is not formally included in any accountable care contracts, Gagliano said. But in Georgia, CVS agreed to manage blood pressure for heart disease patients who are waiting to see doctors with Emory Healthcare, under a contract with the Atlanta-based health system. "It's almost like being the nurse practitioner down the hall," she said.

Mehrotra said the expansion of services offered by retail clinics makes information sharing even more important. These clinics were once limited to flu shots, vaccines and treating simple injuries and ailments during a single visit, such as bronchitis, ear infections and sinusitis. Now, more retail clinics offer monitoring for common chronic diseases, such as diabetes and heart disease. These more complex conditions often require ongoing management with medications and routine testing.

That growth "amplifies the importance of the care coordination issue and the information exchange," Mehrotra said. "Particularly for the sickest, most complex and most expensive patients, the lack of care coordination leads to care that is missed, potential medical errors, excessive testing and frustration from the patients' perspective."

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