Achieving Whole Health A New Approach for Veterans and the Nation (2023) / Chapter Skim
Currently Skimming:
7 Infrastructure for Scaling and Spreading Whole Health
7 Infrastructure for Scaling and Spreading Whole Health
Pages 297-352
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This chapter describes the infrastructural elements necessary to scale and spread whole health throughout the United States. HEALTH INFORMATICS A substantial share of clinical and personal health information now lives online or in electronic platforms.
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. While these advances are necessary to support primary care, they are not sufficient for effectively scaling and spreading whole health because whole health care will require more robust, people-centered tools that gather and sort information about what matters most to individuals, families, and communities and mapping progress toward their goals; extending the use of technology to all whole health interprofessional team members; supporting teamwork through communication, collaboration, and coordination tools; addressing upstream determinants of health which are currently segregated from clinical record systems; promoting accessible and proactive care through virtual technologies and automated functions; and ensuring that technology facilitates care team well-being by being user friendly and
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in the 1970s; made the Veterans Health Information Systems and Technology Architecture (VistA) content open source in the 1980s; developed information exchanges between VA, the Department of Defense, and the Indian Health Service in the early 2000s; launched its My HealtheVet patient portal in 2003; led electronic prescribing in 2009; and pioneered information sharing in 2010 with Blue Button functionality and additional information exchanges (Hogan et al., 2014; Klein et al., 2015)
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Health informatics systems remain siloed; patient access is often limited and non-transferable; information exchanges between systems are rudimentary; there has been insufficient attention to usability and making users' lives easier; systems have not incorporated many of the technological innovations available to improve functionality; and EHR vendors and health systems can maximize market power by limiting or even blocking the flow or exchange of health information (Everson et al., 2021; ONC, 2015; Vest and Kash, 2016)
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Specifically, the 21st Century Cures Act mandates that health informatics systems adopt standardized application programming interfaces (APIs) , which will allow individuals to access structured electronic health information using smartphone applications securely and easily (ONC, 2022a)
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. Other integrative health resources that VA integrative health coordinating centers offer include websites; videos; audio/podcasts; journals; online classes for yoga, meditation, Pilates, and tai chi; biofeedback experiential resources; and meditation/guided imagery experiential resources.
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Team members span clinical and community care settings and include conventional medical care, new medical services, integrative health approaches, and social services delivery. Veterans may receive whole health care services in both VA and civilian settings.
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. There are unique challenges to including community and social service providers -- essential whole health care team members -- in health information exchanges that interoperability alone will not solve.
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The MISSION Act's focus is primarily on providing veterans access to community health care partners, including those that provide integrative health approaches, but not to community and social services providers. VA Direct is a secure system that allows the exchange of select health information to and from community partners.
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. Health Informatics that Supports New Whole Health Services Health informatics are needed to support whole health services that extend beyond conventional medical services, such as personal goal setting and care planning tools, wellness programs, health behavior change support, community and social services delivery, educational resources, homebased biometric/telemedicine monitoring systems, and complementary and integrative health services and programs.
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. VA and most health systems' EHRs and patient portals currently include functionality to support virtual visits, but this functionality will need to be extended to more of the unique whole health services, such as goal setting, yoga, tai chi, or health behavior change classes; include more community and social service providers; and be delivered from more settings, such as community programs.
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Effectively delivering these services requires telehealth and remote monitoring for people to access care but also other virtual technologies that have not been well developed or utilized in health care. Examples include but are not limited to virtual group meetings, interactive sessions to support health behavior changes, and novel strategies to deliver high touch complementary and integrative health services.
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. Health informatics systems can promote team member well-being and improve care delivery experience by saving time.
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, and other allied health professionals to deliver care through a team-based whole health approach. Provider organizations can build and nurture high-performing interprofessional teams designed to meet the specific needs of the communities that they serve while maintaining an orientation toward whole health of the population rather than health care services rendered.
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A 2021 health care workforce survey found that 55 percent of the workforce reported feeling burned out and 29 percent reported having considered leaving their profession because of burnout (Kirzinger et al., 2021)
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Even with the most supportive and thoughtful policy supports, it could take decades of intentional and persistent efforts to build a workforce that reflects the diversity of populations at the local level throughout the United States. Health care systems, however, can rapidly expand opportunities for some professions, such as CHWs, health coaches, care coordinators, and health educators, all of which are generally more diverse professions, require less training than clinical professions do, and play key roles in the scaling and spreading of whole health (IOM, 2003; Jackson and Gracia, 2014)
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Preparation Training the health care workforce is unlikely to lead to sufficient cultural transformation if the workforce does not offer informed commitment and ongoing support at all levels of the organization or if health care delivery organizations are not committed to act on whole health principles when the initial training is rolled out. This includes readiness to engage the population it serves as well as its own workforce.
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VA's LHS programs are also designed to reach beyond clinical settings to increase the diversity of the health care workforce and address persistent gaps in health outcomes among populations that have been historically marginalized. Participants without terminal degrees are eligible to participate in some programs,
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As Chapters 4 and 5 describe, VA's WHS, as well as most of the other systems the chapters highlight, have developed employee wellbeing components in their whole health approaches. However, most program components addressing employee well-being are individual-level programs and interventions designed to help employees improve their personal wellbeing through stress management techniques, town hall meetings, and other activities.
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created guidelines to help health care organizations integrate well-being systems into their overall care delivery system (Box 7-3)
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. • Use a systems approach to proactively improve professional well being while supporting patient care.
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. Nevertheless, these efforts at VA, combined with the universal perception of a pressing need, the availability of high-quality whole health training programs and materials, and the concerted efforts of health coaches, peer-support specialists, clinical champions, mental health professionals, chaplains, employee health workers, and facility leaders helped to advance robust whole health implementation at VA facilities where earlier efforts had stalled.
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Policy Considerations While individual health care delivery systems may choose to transform to whole health, workforce development at the national level will require action at the federal level. More primary care clinicians are needed to anchor whole health systems (NASEM, 2021)
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A large body of literature is aimed at understanding both the state of performance on quality measures and to what extent financial incentives can improve the quality of care. In general, the quality of care delivered in
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. Efforts by insurers to improve quality through financial incentives have led to some improvements in performance on quality measures, but have also introduced important unintended consequences (Berwick, 1989; Rosenbaum, 2022b)
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While specifying a standard set of learning and accountability metrics for whole health is beyond the scope of this report, the committee emphasizes that identifying such measures should occur through a coordinated process involving key stakeholders, including community members. Such efforts should seek to identify existing measures that reflect whole health foundational elements as well as important gaps that may require new measures for advancing whole health.
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not often addressed in clinical settings. • Distinguish measures valuable for learning from those intended for accountability.
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Scaling and spreading whole health will require new measures that better reflect the five foundational elements of whole health, but these measures may need to be developed over time within iterative quality improvement and translational science processes. Consideration should be given to structural and processual measures, such as team-based care and care integration; cognitive measures, such as trust (Lynch, 2020)
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. Nevertheless, the health care system itself -- including not only the human capital necessary for delivering care but also the physical and now increasingly virtual structures of care delivery -- retains an important role in determining whether and how a vision of whole health can be achieved.
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Payment models include reimbursement for each service rendered according to a fee (or price) schedule, often known as "fee-for-service"; bundled or episode-based payments determined prospectively by a target or budget for a defined set of services over a period of time; and payment determined prospectively for all services across the spectrum of care for a defined population over a period of time.
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goes to programs for community care, which through the MISSION Act (see Chapter 6) enable veterans to receive care outside of VA when care would be challenging to receive because of wait times, long travel distances, or the unavailability of a service inside VA.
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By paying its hospitals according to a budget and its clinicians via salary, VA has a basic foundational payment infrastructure that encourages its delivery system to care for patients holistically and that emphasizes prevention, as additional use does not immediately garner additional revenue. Paying hospitals and clinicians in a more budgeted or prospective manner aligns with the philosophy behind value-based payment models that emphasize prevention, primary care, and reducing low-value care.
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In recent years, both private and public insurers, including Medicare and Medicaid, have begun to move payment arrangements away from feefor-service and toward "prospective" or "alternative payment models" that provide clinicians and health care delivery organizations a spending target or budget for a set of services or the care of an attributed population of patients (Burwell, 2015; Emanuel et al., 2012; Rajkumar et al., 2014)
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By 2021, about 40 percent of U.S. health care spending flowed through such alternative payment models (MITRE Corporation, 2021; Health Care Payment Learning & Action Network, 2022)
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. A payment model based on a spending target or budget with only upside risk is often denoted a "one-sided" alternative payment model, whereas a model with both upside and downside risk is often dubbed a "two-sided" alternative payment model.
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. Net savings can be understood as savings generated for the payer or society after accounting for incentive payments to providers, which include the shared savings, quality-based performance bonuses, and other non-claims-based or per-member-per-month payments to providers to help them adapt to the new payment model (e.g., lump-sum care management fees or investments to help providers establish electronic health records)
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. Outside of primary care, Medicare's largest mandatory bundled payment model, the Comprehensive Care for Joint Replacement Model for hip and knee replacements, demonstrated modest savings on claims in the first 2 years which were driven by changes in post–acute care, but those savings were largely offset by incentive payments (shared savings and quality bonuses)
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Beneficiaries can choose to enroll in traditional Medicare or a Medicare Advantage plan, based on the plans available in their county of residence. By accepting a prospective payment, Medicare Advantage plans have a strong financial incentive to adopt a whole health philosophy in their population health management.
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. Recent Evidence from Commercial Insurers Analogous alternative payment models, notably ACO contracts, have also proliferated between commercial insurers and provider organizations.
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Indeed, provider organizations and some payers, including Medicare Advantage plans, that operate under a global budget model have increasingly contemplated or sought to invest in such social services. For example, some
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Third, from the financial risk perspective, prospective payment models that support whole health could enable provider entities within VA, such as hospitals and clinics, to assume more accountability for quality and spending that veterans incur within their federally allocated budget. This accountability could include incentives for providers to retain savings under the budget.
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However, the need to scale and spread whole health care underscores their urgency. Advancing infrastructure related to health informatics will require developing systems that are more patient centered; enable data sharing among interprofessional team members and end users; foster teamwork through communication, collaboration, and coordination tools; support data collection for whole health services beyond conventional medical services; support more accessible and proactive care, including care at home, through virtual technologies and automated functions; foster team wellbeing; and improve the care delivery experience for patients, families and communities.
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Prospective payment models, including bundled and global payments that aim to improve the value of care, align better with the philosophy of whole health. However, substantial evidence suggests that the savings are fairly modest and that the observed quality improvements are generally limited to process measures rather than improvements in health outcomes.
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2019a. Postacute care -- The piggy bank for savings in alternative payment models?
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2019. Human factors and usability for health information technology: Old and new challenges.
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2021. Information blocking remains prevalent at the start of 21st Century Ccures Act: Results from a survey of health information exchange organizations.
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Health Affairs Forefront. https://www.healthaffairs.org/do/10.1377/ forefront.20220223.736815/ (accessed November 10, 2022)
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2014. Capturing social and behavioral domains in electronic health records: Phase 1.
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2017. Projected coding intensity in Medicare Advantage could increase Medicare spending by $200 billion over ten years.
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2022. Association of Medicare Advantage vs traditional Medicare with 30-day mortality among patients with acute myocardial infarction.
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2021. APM measurement: Progress of alternative payment models, 2020–2021 methodolgoy and results report.
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2019b. Hospitals' use of electronic health records data, 2015–2017.
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2021. Health care utilization and spending in Medicare Advantage vs traditional Medicare.
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2021a. Veterans Health Administration: Health Information Strategic Plan fiscal year 2022-2026.
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2020. Improving VA and select community care health information exchanges.
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2019. Five-year impact of a com mercial accountable care organization on health care spending, utilization, and quality of care.
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