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

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.