An introduction to building software for value-based care

I attended a talk on 'The Future of the EHR' and noticed a significant gap between the presented capabilities and what I observed driving great care at Cityblock. At Cityblock, our ideal electronic health record (EHR) resembled a customer relationship management (CRM) tool with a side of EHR. Given this disparity, I wanted to reflect on my journey as the first engineer and head of engineering for Cityblock Health. What did we do that mattered and why? Our aim at Cityblock was to improve the lives of people in underserved communities. However, our engineering and product team primarily consisted of professionals from non-healthcare backgrounds with innovative ideas for supporting our staff. Some concepts included voice/dictation capabilities, radically simplifying tasks/collaboration, a command line interface, and automating care plan management. Interestingly, our most successful projects were relatively modest builds, such as: - UI, policies, and procedures for care workers to text patients - Real-time integrations with health information exchanges (HIEs) that drove immediate in-person interventions, primarily around hospital admissions - Spreadsheet import/export functionality for matching providers and patients and rebalancing care teams Why did these seemingly simple features matter, while many others didn't? Let's explore what value-based care is fundamentally about.

### Value-Based Care Value-based care is about putting patients first in everything we do - that is the singular core value. The patient is our customer, and our complete focus is providing excellent service to our customers over the long term. However, as software builders who don't directly see patients, how do we effectively "put patients first"? We put patients first by helping care workers implement appropriate interventions. We orchestrate the right people, in the right place, with the right information, at the right time. > I use "appropriate" here instead of "right," "correct," or "ideal" intentionally. > The tech team builds trust through making and keeping promises with our staff and patients. Within the scope of value-based care, the most effective path is to provide consistent, easy-to-understand, and dependable solutions across all challenges the staff face.

### What is Value-Based Care? Value-based care (VBC) is a relatively new approach to healthcare payment. It generally means that medical professionals assume financial responsibility or "risk" for the quality of care they provide. This differs significantly from fee-for-service (FFS), where providers focus on performing discrete tasks well. In FFS, providers manage their reputation, but they receive the same payment regardless of readmissions or complications in the care they provide. They also rarely address issues beyond the medical scope, such as transportation, housing, or mental health. There are numerous value-based care financial models. Most commonly, they take the form of combining many services into one "bundled payment" (such as combining preparation, surgery, and follow-ups for a knee replacement), shared savings, or partial and then full risk (sometimes called "capitation"). Risk approaches are unique since the provider organization can lose money if a patient's costs exceed their estimate. When calculating cost in a risk agreement, medical providers and insurance companies negotiate whether to include the costs of physicians, specialists, emergency visits, and pharmacy. One challenge with shared savings and risk contracts is that they incentivize providers to lower costs - which could potentially lead to (illegally) denying or discouraging services in the short term. To counteract this incentive, most value-based contracts span 3+ years, which would penalize such behavior if it increased costs later. In practice, most value-based care providers focus on reducing emergency room utilization in favor of more frequent and longer primary care or social needs-focused visits. An ED admission costs approximately $2,200 in NYC (Gottlieb et al., 2018), and those resources could fund many hours of specialized in-home services. > Quality measures are another way the health system ensures baseline care. These quality measures might include requirements such as "[ensure each patient diagnosed with diabetes gets their A1c level checked every 12 months](https://mdinteractive.com/mips_quality_measure/2021-mips-quality-measure-001)." Quality measures are updated annually to prevent providers from gaming the system. However, [their effectiveness remains unclear](https://chqpr.org/downloads/Why_Quality_Measures_Do_Not_Measure_Quality.pdf). **Why Not Fee for Service?** A relatively healthy individual we cared for at Cityblock averaged 15-20 emergency visits per month (one every other day) and had not seen a primary care doctor in many years. On the other end of the utilization spectrum, I recently scheduled an appointment with my primary care physician, and the next available slot was three months out. On the day of the visit, I took approximately two hours off work to see the doctor for about 8 minutes and pay a $75 copay. Most readers may not frequently visit the emergency room, but many relatively healthy people do. The ER effectively functions as an as-needed, accessible medical service. People who cannot take time off work, wait months for an appointment, or afford copays rationally use the ER when they need medical attention or are concerned about a health issue. Value-based care attempts to better meet people's needs and align incentives among patients, providers, and insurance companies. I believe this is best achieved when providers develop deep relationships with their patients and act proactively rather than reactively. ### The Value Journey VBC tools support several key stages of the patient-provider relationship. In simplest terms, a provider reaches out to patients, actively listens to them, and then helps them achieve their goals. The process typically includes: - **Outreach**: How can we identify and initiate conversations with our patients? - **Knowledge and Trust Building**: How can we learn more about the actual challenges this patient faces? How can we deepen our relationship to establish two-way communication? - **Population Management:** What interventions can we implement today to reduce the likelihood of more intensive interventions later? What is the most critical intervention for the person who needs it most? A patient will move between these three areas of focus, sometimes in reverse order, such as when a first visit doesn't go well and the provider needs to try another approach to build trust. ### The People Doing the Work Understanding the people caring for patients and their responsibilities is essential before considering technological solutions. People first. A significant insight of the value-based care model is that complex care management requires establishing a trusted contact with the patient separate from individual medical or behavioral specialists. A trusted non-medical contact can provide extended, meaningful visits and higher-quality care at lower costs by serving as the "quarterback" of a broader team of experts. The "quarterback" of the care team (a group collaborating to care for an individual patient) can be a community member who manages the relationship with the patient. They provide trusted referrals to and seek guidance from a team of specialists and a network of community organizations. These specialists may participate in a care team that meets daily. The medical and social needs specialists may co-lead a daily care team meeting or "huddle," but at the patient level, they are typically brought in to address specific issues and/or co-develop a forward-looking care plan with the "quarterback." In terms of relative scale, the "quarterback" may focus on approximately 20 patients, while a specialist like a social worker may serve around 100 patients (NOTE: there is considerable variance here - sometimes the quarterback may manage 100+ patients). **Brief Role Descriptions:** Community Health Partner / Quarterback - Foster lasting relationships as the face of the team and key point of contact - Help patients achieve their goals, identify new needs, and coordinate care - Collaboratively manage care for a population living with complex medical and behavioral health needs NP/PA, RN, and PCP (NOTE: These are very different roles but all focus on medical operations) - Co-manage a panel of complex patients in a value-based care environment - PA/NP: Provide comprehensive care management, chronic disease management, urgent home-based and community-based primary care visits, preventative care, and wellness. Work with relevant providers regarding behavioral health and other specialties - PCP: Diagnosis, treatment, counseling, medication management, acute triage, and follow-up care Social Worker / Behavioral Health / LCSW - Coordinate treatment plans, perform psychotherapy, support medication management, etc. Other team members may include lawyers, transportation specialists, benefits specialists, and more. Beyond the care team, broader management roles exist, such as Medical Directors and Care Management leaders who oversee multiple care teams to ensure quality, compliance, and consistent care models. On the business side, Market Operations professionals analyze entire geographic areas and think strategically about staffing levels, patient populations, community partnerships, and physical resources like clinics or equipment.

**Tech Fluency of Staff** We've briefly examined roles and responsibilities, but it's important to note that healthcare professionals typically use very different tools than office workers. Regarding technological experience, it's generally safe to assume these professionals: - Are adept at using various complex tools and finding workarounds - Don't prefer using iPads for work (a note to every digital health startup) - Share tips and tricks with each other verbally - Have limited experience with Slack/Teams/Discord - Have limited experience with GSuite for documents or calendar management (most medical professionals have administrative staff manage their calendars) - Are comfortable with email but follow different communication norms - Are comfortable with texting or messaging applications > Organizations can hire for technological proficiency, but this doesn't necessarily correlate with job performance at scale. However, when starting small, this approach can help establish initial operations. ### The Role of Technology Technology's primary role is to put the patient first. Tech teams in this domain must rigorously manage resources and focus to provide care across multiple dimensions and address countless edge cases. They must also help the overall business iterate quickly toward a proven effective model. I'll discuss the extensive range of functionality in a future post, but generally, the business needs far exceed the team's capabilities, at least initially. This leads to numerous discussions about whether to build, buy, integrate, or outsource solutions. As a general principle, you should build solutions that are unique to your company and core to your model - areas where you'll need to iterate most frequently. Everything else can be outsourced, purchased, or obtained through partnerships. However, if you cannot find a partner that meets your quality and speed requirements, it may make sense to bring that capability in-house. Here is a diagram illustrating this approach:

In software design, I often emphasize "optimizing for flexibility" and building systems that are easy to modify safely. Ease of modification is far more important than code execution speed. Business realities change continuously. Areas that were not core may become essential, and unique aspects may become less distinctive as the competitive (and political) landscape evolves. While tech teams must creatively address all business needs, in-house teams should focus on areas that are both unique and core to the business; otherwise, your attention will be spread too thin to provide differential value and meaningful innovation. Those unique and core tools may include: - Solutions for selecting, prioritizing, and matching patients with providers ("Which patients can we help?" "Which providers should see them and how often?") - Tools providers use in the field (mobile apps/websites) - Tools that management uses to make informed market-level decisions (reporting dashboards) Areas that are core but less unique might include: - Identifying quality gaps - Scheduling - though the quality of external tools may be insufficient Areas that are not core but unique might include: - Reports for external partners # The Future of Value-Based Care Tools

Value-based care demands a great deal from providers, who urgently need new tools in this environment. I believe the future of EHRs will involve a bifurcation between teams focused on volume and those concerned with value. This is illustrated in the chart above, where providers assuming risk require more sophisticated tools for data collection, analysis, and planning compared to those handling fee-for-service. Beyond performing their jobs effectively, value-focused teams must anticipate future needs and actively engage patients (rather than waiting for them to schedule appointments). Value-based care tools should help care teams manage relationships with their patients and plan proactively to maintain trust and reduce the risk of adverse outcomes. From this perspective, the ideal solution begins to resemble a sophisticated CRM platform like Zendesk or Salesforce rather than a traditional EHR.