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The EHR—on the Road Where a Cottage Industry Lived

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Improving doctors' quality, effectiveness and cost-benefit requires meaningful communication at all levels and settings.

To cure health care's ills, there's an obvious remedy 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. 
 
*Examples using an episode of care,[+] using a grouper like CRGs), measuring proceses and outcomes, sequencing events as in having a longitudinal picture or as stated in the "Next Logical Step," below, a "competitive relay"), acuity-adjustment, and, if all else fails, a context-specific tickler that will remind the practitioner of guidelines.  Note, however, for those without the ability to  demonstrate level II Meaningful Use or even digitally monitor or track patients electronically, for the interim they should use raw claims data for now but not allow incentives to inure to those behind-the-times docs or facilities.

The Next Logical Step—​Patient-focused Episodes of Care

+"A patient-focused episode is a unit of measurement for payment and quality that is defined from the point of view of the patient, not the provider. It takes account of five key things about the patient: the 'trigger' that brings the patient to the hospital, how severely or acutely ill the patient is at the time of admission, the patient’s 'burden of chronic illness' before admission, the scope of services like drugs and physician office visits the patient needs during the pre-and post-hospital portion of the episode, and over these it defines a time period that sets the boundaries (for example, two weeks before admission and 30 days after discharge). In other words, this system re-sets the fundamental unit of measurement in healthcare delivery as a competitive relay, with a defined time period that motivates individual team members to work as a unit toward a single, clearly stated goal—to carry each patient across the episode finish line as efficiently and excellently as possible."

 (3M) "The Healthcare Provider Relay: Why We Need a Patient-focused Episode Payment System." Posted March 3, 2014.  See “Developing A Prospective Payment System Based on Episodes of Care” by Rich Averill and others at 3M.


Key innovations in the next generation of an 'Episode of Care'-type of "bundled payment models include, but are not limited to:
  1. Extending the duration of the bundles

  2. Expanding the accountable entities beyond hospitals 

  3. Integrating bundled payments nested within global budget models promoted to or found within Accountable Care Organizations (ACOs)

This would "better align episode-based payment with population health and offer a smoother path to global budgets."  It is likely that innovations in bundled payment design would "increase their attractiveness to commercial and public payers alike in the pursuit of higher-value care."
 
Navathe AS, Song Z, Emanuel EJ. "The Next Generation of Episode-Based Payments." JAMA. May 22, 2017    

Suggestion: Use a a Small, Dedicated Team To Improve Health Care Delivery

The typical pushback for this is that full-time a "team, even a small one, is just too expensive. But that thinking may just be the residue of an entrenched fee-for-service mindset, where one simply does not deliver services that are not directly reimbursed. Under any kind of at-risk contract, however, these projects have high likelihoods (sic.) of delivering both better outcomes for patients and a financial return on investment."

"The Best Way to Improve Health Care Delivery is with a Small, Dedicated Team." by Trimble, Chris. Harvard Business Review March 8, 2016.


Interoperability (Df.)

"Interoperability is generally taken to mean the ability of two or more systems or components to exchange information and use the information that has been exchanged.2  That means that there are two steps to interoperability: A) the ability to exchange information; and B) the ability to use the information that has been exchanged.  Fast Healthcare Interoperability Resources (FHIR, pronounced "fire") is one way to change how the healthcare industry exchanges electronic medical record (EMR) and other health information technology (HIT) data."   

EEE Standard Computer Dictionary: A Compilation of IEEE Standard Computer Glossaries (New York, NY: 1990).

See "We Are All Patients – The Reason Interoperability REALLY Matters." [It includes a personal case study] and it was posted on March 11, 2015 by a medical informaticist with the 3M Health Information Systems, Healthcare Data Dictionary (HDD) Team.

We need to focus on care workflows based upon the application of interoperability technology

Value-based care models are "designed to increase productivity, avoid duplicate medical procedures, and achieve shared savings as a result of payment by episode of care (an episode payment is a payment for all services needed by a patient for all inpatient and follow up care involved after a major hospitalization event). But to effectively coordinate care, close gaps in care, and manage overall utilization, these models rely on high levels of coordination among providers, which can only be achieved via improved system interoperability.

The takeaway [is that there exists] better ways to share referral documents with patient’s longitudinal records and plan of care among all members of the care team, including the primary care physician, the care manager and providers from the hospital. This workflow can improve overall care coordination, increase productivity and ultimately improve patient outcomes."

Chronister, B. (Platforms, Caradigm). "How Interoperability Can Transform Care Workflows." Health IT Outcomes, posted August 26, 2016


Other digital and analytic interoperability advances are touched upon in "ONC app contest looks to improve physician workflow." by Mary K. Pratt, Medical Economics:8/15/16

  • “If this, then that” alerts based on real-time EHR data; 
  • Population Health Risk Assessment Support Engine (PHRASE) Health clinical decision support platform to help manage emerging illnesses by incorporating more external data sources to identify at-risk patients and by enabling information exchange between public health and frontline providers; 
  • WellSheet web application that utilizes machine learning and natural language processing to prioritize relevant information during a patient visit, taking multiple data sources and presenting information in a single screen.

An Even Simpler Definition of Interoperability: a patient’s data should be accessible to both patients and practitioners, alike, and regardless of where the caring actually takes place. "Additionally, provider access to this data must be built-in to EHR technologies at a reasonable cost for use by a broad range of healthcare providers and the patients they serve."  The CommonWell Health Alliance  See also, Health Information Exchanges (HIE)

By now, most of us expect to always be able to access our cash. But, in comparison, health information is silo'd (i.e., not available from one institution to another). Indeed, less than 2 out of 5 physicians' offices can share that information with other practitioners via a health information exchange (HIE).

"Although most physicians recognize the clinical benefits of efficient electronic exchange of health information—for example, an emergency department being able to access a patient’s medications, allergies and problem lists—the incentives have yet to outweigh the challenges of widespread interoperability, according to Joseph C. Kvedar, MD, founder and director of the Center for Connected Health, a division of Partners HealthCare"

Debra Beaulieu-Volk's "Interoperability remains a challenge for EHR's."  Pub 3/24/14


The need to build a business case for interoperability

"Competing EHR vendors have not necessarily found it in their short-term financial interest to make their systems interoperable. [Nevertheless,] the pressure to achieve interoperability is very strong."

Furthermore, B. Vindell Washington, MD, the National Coordinator for Health Information Technology, asserts that the "barriers to interoperability are not primarily technical." And, some of the drivers for its eventual success are: "building the business case for interoperability, providing recognized national standards and changing the culture to where providers expect and demand it."

Larry Beresford. "Why have EHR's failed to deliver their promissed efficiency benefits?" Medical Economics, Jan. 16, 2017.


An Aid for Communication--Mobile Devices

​"Smartlists for Patients: The Next Frontier for Engagement?" is an article by Latif A, Haider A, and Pronovost P. in the Dec. 14, 2016 edition of NEJM Catalyst, which speaks to using checklists for communication and sharing information:  "The effective use of patient-centered checklists can align required actions and incentives across the vast and complex health care system by (1) ensuring that the same critical information is accessible to both clinicians and patients, (2) supporting shared decision-making, (3) encouraging active participation of patients in their own care, and (4) facilitating the navigation of complex post-discharge instructions. Ultimately, smartphone-based checklists should help care teams and patients work together to improve patient outcomes."


​A promising "destination" for healthcare is value-based reimbursement

In radiology, for instance, one should look for having an "imaging strategy that breaks down data silos and promotes the free flow of imaging information throughout the enterprise and beyond — to physicians outside the firewall involved in, for example, consults and second opinions." We'd rather that kind of interoperability than "continuing .... creating duplicate, unnecessary tests and exposing patient populations to unneeded radiation. [Indeed,] imaging 3.0 will improve patient safety and satisfaction, boost care quality, and create value in a variety of new ways."

Matthew Michela, President and CEO, lifeIMAGE. "How Imaging Interoperability Creates Value For Emerging Healthcare Models."  Pub. online, Nov. 14, 2016


A paradigm-shifting more collaborative, if not accountable model of health care: 

"Imagine if the team at Texas Health Presbyterian jointly authored a single note each day, forcing them to read and consider all the observations made by each clinician involved in a patient’s care. There would be no cut/paste, multiple eyes would confirm the facts, and redundancy would be eliminated.  As team members jointly crafted a common set of observations and a single care plan, the note would evolve into a refined consensus. There would be a single daily narrative that told the patient story. The accountable attending (there must be someone named as the team captain for treatment) would sign the jointly authored “Wikipedia” entry, attesting that is accurate and applying a time/date stamp for it to be added to the legal record."

Tied to or dependent upon that note are "key events: lab results, variation in vital signs, new patient/family care preferences, decision support alerts/reminders, and changes in condition," which will appear on a 'Facebook-type wall' for all allowed practitioners, showing the the contributions from the entire health care continuum.

Halamka, J. "Ebola forces us to rethink how we document in the EMR." Posted on KevinMD Today, 10/27/2014

 


Addendum

Reference for the following material: Medical Economics' publication, "Premium Content Preview | EHR Improvements After the AMA's 'Hateful 8'" an AdvancedMD PDF.  [Note: AdvancedMD will schedule a Live Demo if you call (800) 825-0224.]
 
 

Artificial Intelligence Can Be Built In

"EHRs have transformed from digital versions of paper charts to an interactive tool that physicians use to provide better, more targeted care. Clinical decision support, for example, demonstrates this capability. But AI along with cognitive computing and machine learning (where computers mimic human thought processes and have the ability to learn) could make EHRs even more critical to the practice of medicine."

Artificial intelligence could create smarter EHRs"AI will be an increasingly important player in healthcare IT, with better medical care being an expected benefit."  

Medical Economics, Posted March 16, 2017


The AMA's “'Hateful 8' signs of a poorly functioning EHR:

  1. Interfering with patient care
  2. Poor team communication
  3. Lack of care coordination
  4. Adding to the workload
  5. No custom options
  6. Unwieldy data
  7. Few mobile options
  8. No product reviews or feedback"

Miliard M. "CIOs target population health, patient engagement in 2016." Healthcare IT News. 12/14/15

The AMA’s "EHR Usability Wishlist, 2014 

  1. Enhance physicians’ ability to provide high-quality patient care
  2. Support team-based care
  3. Promote care coordination
  4. Offer product modularity & configurability
  5. Reduce cognitive workload
  6. Promote data liquidity
  7. Facilitate digital & mobile patient engagement
  8. Expedite user input into product design & implementation feedback"

"AMA calls for design overhaul of electronic health records to improve usability." American Medical Association. 9/16/14


 2nd Addendum

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. For this enhanced data set, functiionalities 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."

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

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..... 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."  

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