Defining the HIT Triple Aim

Can we take the concept of the Healthcare Triple Aim (Berwickian) and apply the same concepts to the design, spread, and utilization of EHR tools and other HIT? Here's what this HIT Triple Aims might look like:

1) Improved "health" of a "population" of HIT tools

a) Tools are developed, tested,  and demonstrated to improve the healthcare triple aims. If we spend large amount of resources implementing EHR-based early warning systems for rapid responds teams, we better demonstrate clinical value

b) Tools are more flexible technically. How do we build clinical decisions support tools for populations (transgendered patients, for example) when we can't even define the population within the systems?

c) Proven tools are rapidly adopted. This requires help from our colleagues in education, social media, psychology, graphic design, usability testing, and gaming. And we must create healthcare systems which are learning organizations.

d) How do we increase HIT a science to build tools with high quality and high reliability?

2) Improved HIT User experience

a) We must recognize that users include more than the physicians, but also clinic population health managers, behavioral health providers, dentists, social workers, home health nurses - ideally working in one seamless system. 

b) Patients must be considered as primary consumers (and thus system drivers) of the EHR and other HIT tools. Check out www.MyOpenNotes.org . Would you prescribe a new therapy or medication with negligible side-effect if it led to a 30% improvement in certain clinical outcomes? (NNT = 3; you bet we would endorse it.) It's coming. Get on board.

c) Are we demonstrating value (quality/cost), or improved healthcare Triple Aims with our HIT tools?

3) Decreased total cost of HIT deployment

a) Consider the annual budget of your organozations's IS Department, divided by the number of unique patients or encounters or hospital beds or providers.

b) Consider the annual budget for vendors such as Epic or Cerner (etc) - divided by some numerator as above.

c) Consider the annual Federal budget for HIT (Meaningful Use, etc)...

d) Are we able to innovate and improve at lower cost? How can we do that? Can healthcare IS Departments lower costs and improve the tools by leveraging the Model for Improvement, or Lean, or Six Sigma, or ITIL? Or are we lost in tools and it getting better at how we do business?

I welcome your thoughts!

Tim

#in What if it were covered by health insurance?

If you have have worked in healthcare for more than a week, you have entertained this question, "What if it were covered by insurance?"

Health insurers will pay for a patient's opiate prescriptions month after month, pay for the unintended consequences (multiple office visits for constipation, an ED visit after an accidental overdose, a hospital admission for intractable pain). When the patient wants to get off the meds, insurers won't pay for the three-day In Patient rapid detox admission. So the patient continues down the same path, never getting the care really needed to get well, yet still costing the system a bit here and a bit there, day after day. (Maybe the patient will lose their coverage before the insurer has to make that one-time big payment?)

What if health insurers had to include basic dental care - preventative cleanings, simple fillings, and necessary extractions? How many ED and office visits would this prevent? How much patient suffering would this alleviate? How about covering adult shingles vaccines, tetanus & pertussis boosters, and other immunizations?

Well, the overall cost of delivering care to the population might go down, but the cost to the insurer paying for that one patient might go up a bit in the current fiscal year.

What if? What if the insurance companies had to pay for services with a demonstrated positive return on investment at the population level - even if that ROI was longterm? We would then have a healthcare system with coverage of reasonable services aimed at preventing (or limiting) longterm morbidity costs. Isn't that what we want? Well, it is what consumers and healthcare advocates are requesting. Aside from the lower profit margins for insurance companies (which would still be enviable in almost any market), who would argue against such improvement? Once the argument is put aside, how do we get there?

Two solutions which dovetail:
1) ACOs - improve care, improve access, and share the savings. Win-win!
2) Green Mountain Care Board - finally, consumer advocates can create a sustainable model for healthcare delivery aimed at (drum roll) delivering healthcare (rather than aimed at profit-sharing). If insurance companies want to make a profit in Vermont, they should cover a core set of services determined by a group of bright people with no financial interest in the outcome. Wow. It took two thousand years to find that model?

Both models - or one with elements of each - will need to be the flesh on a backbone of healthcare information technology (#HIT), including electronic health records and their respective patient portals, plus the health information exchange (#HIE) that will link our medical communities across VT (#VITL) into a network of patient data. We are on the verge of moving from medical information to medical knowledge.

I am not naive enough to think that change is easy or painless. Uncertainty creates anxiety. Anxiety breeds discontent. New systems (insurance and technology) will bring changes better for some and worse for others.

The road that we have travelled in healthcare cannot survive. Our own "success" is our demise. We may not like the future, but the past course surely is self-limiting.

Chief Complaint: "CMS structured visit."

As a physician informaticist and one interested in improved quality of care, I generally support the trend of capturing patient encounter information as discrete data. I accept that healthcare providers should render care which is evidence-based medicine (#EBM). I believe in the concept of Patient Centered Medical Homes (#PCMH) and Accountable Care Organizations (#ACO). But I worry that the deeply proscribed nature of medical care in such systems may actually become a model of the Governent Centered Medical Home.

If we are not careful, a patient office visit might consist of my checking 27 boxes, demonstrating we discussed everything from colon cancer screening to flu shots to how many minutes the patient should exercise daily and what they should eat. This could leave very little time for me to ask the patient what they have on their mind. The chief complaint - the patient's words describing why they are seeing a provider - could get lost. We must never lose the patient in the patient care.

We need to remember, through all the reports and acronyms, that the patient comes to our office to speak and to be heard. We go to work to listen and to
serve. Yes, I need to check off 27 boxes for reporting, but I need to translate the goals of population health to the care of one person.

How do we accomplish the two, sometimes conflicting, goals in one patient visit? First, maybe it takes more than one visit. Patients with multiple, chronic diseases will require more frequent care with one #PCP, something the healthcare industry has done inconsistently. (Enticing medical students into primary care will require stronger loan repayment initiatives and higher PCP salaries.)

Second, visits may be longer, not always the 15-minute in-and-out we see across much of the US healthcare system. Time for mandated items; time for patient to discuss their own concerns.

Third, we must match more closely the clinical workflows with the technical requirements for capturing discrete data. Whenever possible, data must flow across platforms electronically, so the patient record in the #EHR knows the date of the last colonoscopy from the Endoscopy software system without secondary manual data entry. The provider must not be required to enter some data in a flowsheet, some data in a physical exam, and more data in a patient instructions field. Imagine a single scrolling screen with a series of discrete drop-down fields which allow the capture of pertinent exam items (DM foot exam), patient goals (exercise), and other needed information. The system pulls the data into the proper clinical decision support tools (sends the patient a message when next tests are due), creates a patient visit summary with specific self-management goals, then automatically copies the note to their endocrinologist, psychologist, and nutritionist. Reaching this vision will require flexibility in programming our EHRs, flexibility in the way providers think about patient care and charting, and flexibility in how healthcare administrators prioritize projects.

I see the changes coming across the #HIT landscape, in conversations at national conferences and around the water cooler at work. I see colleagues engaged in this changes process, and it is exciting to be part of this change.

ACO - Why it matters to you.

#in Accountable Care Organizations (ACOs) will likely impact all of us in the near future - either as patients, healthcare employees, or tax payers.

Currently, healthcare spending is increasing at an unsustainable rate of about 5%, projected to increase to as much as 8% potentially. This represents almost 20% of our national GDP, with 45% of costs covered by government (read taxes). If a really big number makes sense to you, we spend almost 3 trillion dollars per year on healthcare.

What do we get for our dollars? Currently, we pay for what we get. Get an MRI done, pay. See you doctor in the office, pay. Here's the twisted piece for our system of healthcare: it makes money currently only for ordering tests, taking xrays, seeing patients for office visits. If we keep patients out of the Emergency Department, keep them off medications, keep them from needing to come in for appointments - no collection of fees, no paychecks, no hospital. There is no malice on the part of individuals (healthcare is still full of altruism) - it is the system that is misdirected. Preventing disease-related expenses simply doesn't pay.

ACOs are one attempt at flipping that system. If I, as a doctor and as a piece in a healthcare organization, can keep my patients healthy - prevent problems and limit impact of chronic disease - the insurance companies save money. And someday the savings will get shared with my employer (the ACO), and I can still collect a paycheck. Better care, lower cost, shared savings. Value. Since you (tax payer) are spending money on 45% of the cost of healthcare, lower expenses matter to you. Since you (patient) will still get excellent care (likely even improved care based on some studies), you also win.

What's the link to healthcare information technology? ACOs will be required to produce proof that they provide value (quality care and cost-savings). To demonstrate quality, ACOs will furnish 33 reports annually to the government. These include measures for patient satisfaction and access to care, good preventative services (eg colon cancer screening), and management of chronic diseases associated with high costs (eg diabetes). Not only does it take a team of computer programmers to write the software code for the reports, but it will take a team of clinical informaticists (doctors and nurses who work with tech services to improve care delivery) to design the medical records and clinical protocols to gather the right data and drive improved care.

In many situations, giving people feedback on their work will drive improved performance. There is some evidence that telling physicians how often they do (or don't) provide the recommended care will lead to improvements. In addition, electronic charting tools can include automated reminder systems to alert both the physician and the patient (via letter or secure, online patient portal) that they need specific follow up care (eg overdue mammogram). Building these systems requires a large commitment of human resources and capital investment by the ACO (hospital, etc).

Initial experiments of ACOs across the country are providing optimism that this intense level of technical support, reporting, and shared savings can bend the cost curve and cut the growth rate of healthcare spending to below our economic growth rate. Oh yeah - and it can improve patient care, too!

Stay tuned for ACOs near you - they are likely just beyond the threshold.

Patient portals - physician perspective

My patients haven't been using the patient portal long, but so far it is a success for them and for me.

Two concessions up front:
1) I have few patients signed on, so I can't be certain how this will scale up; and
2) It is taking me (and the office staff) a little time to figure out exactly which buttons to use in the EHR.

I jumped in a bit cautiously, not encouraging too many patients to sign up. Months later, my biggest problem is my own doing - too few patients signed up! The technical pieces (which button do I use to send a lab result to Fred?) will only get easier as I do this more frequently.

Have I had any awkward interactions with patients via the patient portal? Well, one conversation stands out. As predicted by the naysayers, I did have one person contact me electronically to dispute the accuracy of his medical history. After some back and forth, we agreed that he did have some kidney problems, not as bad as I had recorded, but this was completely new information for him. I made the EHR more accurate; he learned more about his health. We ended the conversation on good terms.

In my last blog, I expressed my frustration with data silos. The patient portal is a great tool to connect the dots, see the data, correct errors, deconstruct the silos. The portal is also exactly what we hoped it would be: a window for the patient to understand his or her own health.

In the past two weeks I have tried to introduce more of my patients to their portal. It's hard - face-to-face time in the exam room is limited, the topic falls of my mental radar quickly as the day gets busy, patients come in with a list of things to talk about. But what could be more important for a physician and a patient to discuss than the medical record itself? The accuracy and completeness - and the very access to the data - these are really at the core of the service we provide to our patients and for our patients.

(Oh, and there has not been a tidalwave of problems as feared. It has been pretty smooth.)

#EHR #patientportal #PCMH

Too much EHR, not enough HIE

#in Vermont is good farm country. We like silos. They are as much a part of our landscape as the mountains. It seems that we are still building new silos here - information silos.

In a time when EHRs offer us the chance to share data across vaste geographic spaces with only a second delay, we are building too many EHR silos without interconnectivity or data exchange.

I spoke recently with a physician at one community hospital in Vermont. While admitting a patient from the ED, he has to surf through no fewer than 5 EHRs. The patient lives at a nursing home (EHR #1), sees a PCP in a local clinic (#2), and is now in the hospital ED (#3). The same patient was admitted to the same community hospital a month ago and was on the med/surg floor (#4) for two days before being transferred to the regional tertiary care center (#5). [And the local dialysis unit is on EHR #6, while the community hospital ICU remains on paper charting.]

With enough RDPs, gateways, virtual servers, tokens, and a dozen passwords, the physician can access all the data. Does that mean that access to patient information has improved with the implementation of all these EHRs? I'm not sure. When the allergy lists disagree, which is the source of truth? When unverified data from one EHR are copied into another blindly, do we perpetuate inaccuracies? We lose data integrity rapidly as we build silos.

I'm a big proponent of healthcare information technology. We must be very deliberate as we proceed. Only with information exchange, data sharing, and system integration can we improve care. Without such standardization, an EHR is only an expensive pen.

Systems broken, not providers

The coming changes in in healthcare, both here in Vermont and nationally, are an indictment of a broken and inefficient system. The changes are not an indictment of individual providers, their compassion, the quality of care they provide individual patients, or the hard work they do every day.

I am currently working with a community physician who uses one EHR vendor. He wants to get records from a local hospital - on a different computer system - into his EHR. Although technically possible, the task is blocked by many social, political, and economic boulders. The data gridlock is not the fault of any person, but the result of complex systems. Yes - we
could be doing better. No - this does not mean we are failing.

Another colleague recently listened to a talk about #PCMH. She was offended at the idea that an administrator felt she was not already providing quality, comprehensive care. Somehow she took it personally. This provider-centric view misses the point. It's not about us as healthcare providers, not about our dedication, not about our work ethic. Trust me, a family physician in Vermont is not in the game for money or glory. Got it. But we can't be such martyrs that we are unable to measure what we deliver and improve how we deliver care.
The deal with #PCMH is not the provider, it's the standardization of all providers. It's about getting the system so finely tuned that lab results always get back to the provider before the next office visit, that every diabetic patient has an A1C on time, that all smokers have a pneumonia vaccine. These goals cannot be accomplished by scattered providers in their clinics trying hard. The systems have to drive the care.
For many of our quality metrics, we consider that we are doing well with 50% adherence to a standard. If we are really on our game, we might hit 90% of goal. Would we celebrate that as success in banking?
Value in healthcare is high quality at low cost. Value happens only with standardization. Standardization happens only with measurement. Measurement happens only with #EHR. This is the fundamental task of #PCMH. Really, it is not about the provider. It isn't really about the patient. It's about the system.