Improving doctors' effectiveness and cost-benefit

For anyone who has hands on experience managing care in a health care organization of any type, there's an obvious answer that is difficult, but not impossible to implement—make cogent information* available at the point of contact with the patient, regardless of setting and within HIPAA constraints. 

*Example, process, outcome, sequence of events (longitudinal picture), acuity, grouper (e.g., CRGs) and even context-specific ticklers of guidelines.  Note, however  for those without an electronic health record (EHR), use their claims data for now but not allow incentives to inure to those behind-the-times docs or facilities.

My proposal is, in a word, "communication; it is critical for health care and as a competitive business strategy that will address spiraling health care expenditures, unwarranted variation in practice, accessibility issues and gross inefficiency, if not cost-ineffectiveness.  It is not a new idea, only one whose time has come in keeping with the fact that we are no longer a cottage industry!

The kind of communication I am referring to is effected as soon as one provides relevant information at the point of service (POS).  Process and outcomes data, standards, guidelines and reminders/alerts, for example, are translated into appropriate information that can be delivered succinctly and unobtrusively at the point of contact with the patient.  As a result, "Meaningful Use" data becomes POS information, now readily available to assist in medical and surgical care.  This form of feedback at the POS and the government and market push for an EHR, then will truly become what has been said to be the "single most potent federal effort to change health care delivery in the past 2 decades." [Statement released by HHS on July 13, 2010]  

The whole idea of effecting change in practitioner and support staff behavior requires incentive alignment for all the relevant players—patients, practitioners and public health operatives. Patients have to be 'incentivized' to be compliant with recommended treatment options, lifestyle management and follow-through; practitioners to follow peer-reviewed guidelines and explain when they deviate from specialty-society standards of care; doctors cannot be paid per visit or make money off of tests; doctors should earn more when they do better, not more for patients; hospitals should not usurp PCPs; hospitals at risk should not inflate charges of do unnecessary procedures; mental health and social services must not be neglected, ETC.

Why require meaningful use?

Simply adopting electronic heath records (EHRs) will not improve care, substantially.  Thus, "policy makers focused on scientific evidence supporting use of 1) electronic prescribing, coupled with 2) decision support to improve quality and widespread sharing of clinical data to lower costs [i.e., health information exchange -- clinicians and hospitals]. In addition, Congress required 3) automated reporting of quality performance to augment existing efforts to increase transparency." [Numbers added for clarity, jgk]

A proper EHR should include "electronic prescribing, health information exchange (sharing clinical data among clinicians and hospitals), and automated reporting of quality performance. The final meaningful use rule incorporates these three challenging requirements that clinicians and hospitals must meet to receive incentive payments. Other requirements include electronically recording key parts of a patient's history (detailed demographics, vital signs, active medication and problem lists, smoking status), creating care-summary documents, and implementing at least 1 clinical decision support tool. Functions that are optional (for now) include the ability to generate lists of patients with specific conditions, using EHRs to provide patients with educational materials, performing medication reconciliation, and submitting key data electronically to public health entities. Many clinicians and hospitals will struggle to achieve these goals in a timely fashion."

"Meaningful use provisions will help improve legibility of clinical records, reduce prescription errors, improve adherence to guidelines, improve patients' access to their records, and ensure that clinicians and hospitals are capable of exchanging clinical data. These are essential first steps. However, for HITECH to be transformative, substantive payment system changes are needed. Although meaningful use makes greater integration and coordination of care feasible, hospitals and clinicians need incentives to actually integrate and coordinate care. Despite good intentions, the Accountable Care Act leaves intact a system that primarily rewards quantity over quality and fragmentation over integration, offering little hope that meaningful use will have more than a modest effect. The administration has hinted that starting in 2013, meaningful use may become more stringent, requiring clinicians and hospitals to demonstrate improved outcomes."

Jha AK. "Meaningful Use of Electronic Health Records; The Road Ahead." JAMA Jan. 26, 2011;305(4):1709-1710

Again, why Meaningful Use? When the quality of medical care suffers, people are harmed

"The core purpose of a health system should be to maximize the health of the population. When the main challenge is managing long-term conditions, maintaining health rather than delivering health care per se should be the goal....[in fact,] Quality, effectiveness, and efficiency are the goals.  Traditionally, physicians and other health care professionals have regarded financial efficiency as outside the scope of their professionalism (indeed, often at odds with it). The concept of value—useful health outputs divided by the resources needed to achieve them....is relatively new and unfamiliar to many clinicians.... However, to make progress on value requires being clear about what the numerator of the value equation should describe. This must be quality of care as expressed by useful health outcomes, relevant to patients."  

Please see the original article for references and excellent review of the topics of process verses outcome, continuous quality improvement, episodic snapshots where we should be looking at the whole pathway of care (the system), and let me quote as it is difficult for me to get to the original text:

"Many health care institutions and clinicians object that their business only encompasses a small section of the whole pathway. Although this is true, it is also precisely why a more holistic way of measuring quality is needed. A high-value health system not only deals effectively and efficiently with acute stroke, but also reduces the incidence of stroke (through risk stratification, targeted management, patient education, and primary care) and is also concerned with rehabilitation and secondary prevention. Focusing on the acute phase risks optimizing 1 part of a continuum,and missing the opportunity for prevention, which can obviate the need for expensive "rescue" care. By contrast, a whole-pathway quality measurement approach, focused on relevant outcomes, will promote working arrangements (and payment systems) better aligned with the core purpose of the health system—health, not health care."

James Mountford, MD, MPH; Charlie Davie, MD "Toward an Outcomes-Based Health Care System; A View From the United Kingdom"