Introduction

There has been a rapid advancement, and subsequent adoption, of medical technological innovations in the U.S. over the last couple of decades, which has fundamentally changed the healthcare delivery system.¹ While internal medicine may not be considered a specialty in which technology plays a crucial role, advancements such as healthcare information technology (HIT), care coordination software, and telehealth are critical components of an internist’s practice. This fifth and final installment of the five-part series on the valuation of internal medicine services will discuss technological advancements that impact the providers of internal medicine.

Health Information Technology

HIT includes a variety of software applications such as billing software; staffing models; and, electronic health records (EHR).² The effective use of HIT by internal medicine practices to facilitate quality improvement (QI) can help these practices improve their ability to deliver high quality care and improve patient outcomes.³ Research indicates that implementation of HIT may lead to improved efficiency and quality management.⁴ For example, use of EHRs have resulted in cost savings, improved quality, and better coordination of care.⁵ Physician practices in particular may experience the benefits of EHRs, as they have been shown to increase efficiencies and cost savings.⁶ Further, EHRs are linked to clinical improvements, which could financially benefit the operations of internal medicine physicians and their associated practices. ⁷ Providers using EHRs can access a comprehensive view of each patient’s history to gain a better understanding of patients’ needs, and the content of every provider-to-provider and provider-to-patient telephone exchange and fax is captured electronically within this system.⁸ Providers also have access to progress notes from specialist visits and are notified of emergency department visits or hospitalizations.⁹ Such benefits become more crucial for internists who participate in value-based reimbursement (VBR) models, as these models require physicians to eliminate fragmented care and work with other providers in their model to provide streamlined, efficient care for a defined patient population.

Despite the potential benefits of HIT, adoption of this technology poses significant administrative and cost burdens to independent internal medicine physician practices.¹⁰ However, there are some exceptions to the Stark Law that protect:

1. The sharing of HIT with “community providers and practitioners, in order to enhance the community’s overall health…;”¹¹
2. The donation of EHR items and services to a physician by an entity (e.g., hospital);¹² and,
3. The donation of cybersecurity technology and related services “necessary and used predominately to implement, maintain, or reestablish cybersecurity.”¹³

So long as all of the factors contained within a given exception are met, the donation of these items and services by a hospital or other entity to an internist would be found to be compliant with the Stark Law, eliminating those aforementioned administrative and cost burdens.

Care Coordination Software

Care coordination software (also referred to as care coordination information technology, or CCIT) refers to software applications designed to enable various functions related to managing the care of a provider’s patients.¹⁴ This technology has been the focus of many digital healthcare companies, with the U.S. care coordination software market expected to grow to $3.18 billion by 2022 (up from $1.55 billion in 2019).¹⁵ The components and capabilities of such software vary widely, but may perform tasks as automating: referral management; communication to a patient’s care team (e.g., automated email updates to patient status and patient hospital admission/discharge); delivery of discharge instructions and next steps to a patient’s primary care provider; and, reports that provide real-time utilization trends, outreach success rates, and no-show rates.¹⁶ These technologies are also being aided by artificial intelligence and blockchain technology, “which support data interoperability and normalization within a defined clinical network.”¹⁷ Among other capabilities, these technologies allow for constant, two-way communication among providers in the acute, post-acute, and internal medicine spaces. This is significant as communication (or lack thereof) among providers in these spaces tends to be the root of many care coordination issues. Besides automating referral management and boosting patient revenue and satisfaction, CCIT offers potential to communicate patient outcomes in real time and realize savings from improved chronic disease management and community health efforts. Internal medicine practices can benefit from utilizing CCIT because providers often care for patients with multiple chronic diseases.

Similar to HIT, CCIT, as well as other data analytics, will be needed by participants in VBR models, which typically rely on pre-established benchmarks and require participants to report on patient outcomes.¹⁸ However, much like HIT, adoption of these technologies poses significant administrative and cost burdens to small providers.¹⁹

Telehealth

Telehealth facilitates the delivery of health-related services via telecommunications technology.²⁰ Telehealth services can supplement or replace face-to-face encounters with physicians. Telehealth services show great potential for helping to meet the growing demand for medical services and the shortage of physicians. Moreover, telehealth services can be more cost efficient for both the patient and the provider than face-to-face encounters.²¹ As more studies validate the efficacy of telehealth services, more payors are offering coverage of telehealth services.²² The COVID-19 public health emergency (PHE), which began in March 2020, was a catalyst for unprecedented increases in telehealth utilization across the U.S.²³ Several policies and developments have helped to fuel this rapid expansion. A number of relaxations and flexibilities for telehealth reimbursement and coverage were put in place by the Centers for Medicare & Medicaid Services (CMS), including allowing beneficiaries to receive care wherever they were located – even from out-of-state providers.²⁴ These measures represented dramatic changes from the previous policies, which only covered telehealth for rural patients, had stringent restrictions on the originating site for the care, and only allowed internal medicine physicians to utilize the technology to provide care to established patients (i.e., not new patients) in the same state in which they were licensed.

In addition to relaxing the originating site requirements, CMS also expanded the number of services that could be provided through telehealth. An additional 135 services, including emergency department visits, were added to the list of covered (and thus reimbursable) services for Medicare beneficiaries.²⁵ While all of these flexibilities and expansions were originally only valid for the length of the PHE (which is ongoing as of the publication of this article), CMS has been considering the extension of some expansions in covered services and reimbursement semi-permanently or permanently. For example, CMS’s 2021 MPFS final rule included expansions to reimbursement for telehealth services.²⁶ Under the final rule, nine codes were covered permanently and 59 will be covered through the calendar year in which the PHE ends.²⁷ The 2022 MPFS final rule included an extension for those services that were temporarily added to the telehealth list during the PHE to 2023 (previously, coverage for these services would end at the conclusion of the PHE).²⁸ This will provide CMS additional time to gather sufficient data for those services, with the intent that they may be added on a permanent basis.²⁹

As it increases in ubiquity (and coverage), telehealth will likely augment care coordination activities, leading to new opportunities for internal medicine providers to reduce healthcare expenditures.

Conclusion

One of the keys to advancing the healthcare delivery system’s shift toward VBR models is technological advancement. These models, which require providers to provide cost effective, high quality care and report numerous patient care metrics, require the use of EHRs, CCIT, and other HIT. Further, the ability to connect with patients quickly through telehealth, before a medical condition advances to the point of requiring hospitalization, will help internal medicine providers achieve VBR benchmarks, i.e., provide higher quality patient care at lower cost to more patients, the  “trifecta” of healthcare.