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.

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!