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.

VT Gov at FAHC Med Staff Mtg

VT Gov. Shumlin spoken Tues night at the Fletcher Allen Health Care Medical Staff meeting. The audience represented half of the medical care delivery system for the entire State of Vermont - physicians who have much at stake in this debate. For people who have dedicated 15 years to specialty training and decades of practice, changes are daunting.
Gov. Shumlin's poor selection of medical anecdotes aside, I believe that he is correct on two counts. First, the current trajectory of increasing healthcare spending will destroy this State if left unchecked. Second, Vermont is the best place for such reforms to succeed.
He focused his comments on three areas:
1) reducing overhead costs on the billing and reimbursement cycle
2) leveraging technology to reduce duplication of service
3) using preventative care and improved chronic disease management to bend the cost curve downward.

The first topic I'll leave aside - the billing and reimbursement - except to say that I would believe that our inefficient claims system with prior authorizations, variable drug formularies, and overburdening paperwork may well allow for 8% cost reduction with simplification and lean re-engineering.
On the second topic - healthcare information technology (HIT) - I am a big supporter of these systems in general. Vermont Information Technology Leaders (VITL), our State HIT Extension Center, is helping move practices toward electronic records, is negotiating the policy changes needed, and developing the infrastructure for healthcare information exchange (HIE). FAHC, since going live with its EHR two years ago, brings a huge portion of the State into the EHR age on a single, integrated platform. FAHC is bringing others along by discounting the EHR to local medical practices. Nevertheless, the State as a whole remains largely in paper records at many community hospitals and practices, and even as we implement EHRs at these locations, the creation of disparate systems across the State means that full integration of data across platforms is still well in the future. The goal, as described by Gov Shumlin, of having your entire medical record available and encoded in the insurance card, is still science fiction. It is possible, but it is futuristic. I'm the last one to say we should not attempt the effort because the tools don't yet exist. We have already demonstrated significant interoperability and connectivity (for medication lists, for example) in VT. We have a long road ahead before the HIE taps begin to flow. On an exciting note, I was at a meeting last week which demonstrated real-time transfer of CT scan images between hospitals. In the case of critically-ill patients being transferred to FAHC, this could significantly decrease duplicate images (since the original CT scan now usually is not available when the patient arrives at FAHC and thus gets redone). Soon, lab test done at CVMC will be visible seamlessly to FAHC physicians, again refucing waste and duplication. Bottom-line: incremental gains in the next few years are realistic, but how much this translates to significant savings in the short term is unclear. Still, we need to push HIT and HIE forward for the day when it does pay dividends.
On the third topic - prevention and disease management - we are already demonstrating cost reductions in VT with projects such as the Patient Centered Medical Home (PCMH). This system of comprehensive healthcare services, based in a primary care clinic, led to a significant decrease in ED and hospital admission rates at FAHC's Aesculapius clinic, comparing the 2 years prior to and 2 years after PCMH implementation. The graphs are impressive.
Vermont already has proven that we can deliver great care (best in the country by several measures); Vermont providers are dedicated, smart, hardworking; but the vestigial systems of care are strangling us. I do believe that using many of the tools employed by other sectors (Lean, Six Sigma, etc), we can make the system better without working longer hours.
It is going to be scary making this leap, but we have little choice. The status quo is not sustainable for Vermont or for Vermonters. Whether you agree with his approach or not, Gov. Shumlin has taken on a critical issue not likely to make him many friends. By one definition anyway, this is leadership. Fortunately, he has created a panel including two physicians. The coming months will be interesting here in Vermont. Time will tell if efficiency, technology, and prevention/disease management can pay off.
It is always my attitude that change is coming, and I'd rather direct the change the be caught at its mercy. Its messy either way, but I'd rather be the windshield than the bug!