July 30, 2009

Electronic Health Records and the Health Reform Agenda: Creating a Health Care Intelligence System

The Certification Commission for Health Information Technology (CCHIT) has created a “Meaningful Use Matrix” that shows what constitutes “meaningful use of certified electronic health records”, presented in the context of policy priorities of the Department of Health and Human Services.  Medicare will begin paying incentives in 2011 to practitioners who can demonstrate that they meet these criteria, but what must be kept in mind is that EHR is just a means to an end.  DHHS policy priorities affect practitioners whether they adopt EHR or not.

The annotated Meaningful Use Matrix gives the policy priorities, the respective goals to be achieved within each, and the key performance metrics that will be used to gauge that achievement as phased in for the years 2011, 2013, and 2015.  The policy priorities are:

  • Improving quality, safety, and efficiency in health care and reduceing health care disparities
  • Engaging patients and families
  • Improving care coordination
  • Improving reporting for public health
  • Ensuring adequate privacy and security protections for personal health information.

Those who listened to President Obama talk about health care reform on July 22, 2009, heard him couch the cost containment issue in terms of “paying for what works”.  In health care, few people are inclined to second-guess their physician’s treatment recommendations because as a rule we just don’t have that kind of knowledge.  We are not doctors, and we have accorded those who are the same kind of reverence we do to a priest (even if we are neither Catholic nor catholic).

We shouldn’t.  We need to adopt a more consumerist approach to health care, which means using the resources at our command to evaluate the medical advice we receive in terms of costs and benefits.  Up to now, those resources have been pretty meager, and a major thrust of the health care reform agenda is to provide more and better information to health care consumers.  Whether you have an acute, potentially life-threatening condition or one that is a chronic nuisance and a minor inconvenience, you are entitled to know the courses of treatment that have been proven most effective – both medically and economically – and their associated risks.  This is information for which we have traditionally relied on the physician’s expertise, but in a field as complex as medicine, relying on a single source for such information is itself risky.

DHHS intends to collect information from practitioners that can be made available to consumers over the Internet.  Whether they have adopted electronic health records or not, by 2015 physicians will be required to report this information, which will be ridiculously expensive to produce from paper patient records.  So while adopting EHR is not exactly mandatory, it is no longer optional, either.

Electronic medical record systems capture clinical transaction data in a structured form that can be aggregated into an EHR and analyzed using a variety of criteria.  When President Obama talks about “paying for what works”, he is saying the health care system should be looking at the aggregate experience of all patients having a given condition to determine the combination of treatment steps that have been most successful in alleviating the condition.  This is classic decision support and (in other contexts) Business Intelligence.  We can think of it as Health Care Intelligence.  DHHS could create a health care information warehouse that can be used by everyone to make more informed health care decisions.

But there is more.  In any other industry, a consumer makes decisions about what businesses to patronize based on a variety of inputs, including how the business handles its customers, and how well it delivers on its promises of service and quality.  While much of this is subjective, there is enough objective information available that you can, for example, shop for a car using the Internet to focus on the two or three models that you would like to test drive, and for the dealer who is most highly rated by other customers.  Selecting a doctor is harder, because nearly all the information is subjective.  A Health Management Intelligence program would make more objective physician data available when you go shopping for a doctor.

The DHHS key performance metrics for each practitioner would be available to be compared with the aggregate metrics for all practitioners in the region and in the country.  The consumer could call up a report, for example, that rates a practitioner for “use of high-risk medications”, “% of diabetic patients with ALC under control”, “% of patients with access to patient-specific educational resources”  and similar performance benchmarks.  The collection of these metrics says something about the physician’s approach to health care that the patient can decide whether it is to his own liking.  It opens up competition in health care to the kind of information on which we base other decisions every day.

It will be some time before such a capability appears, but I think this is the direction health care is going to take.  I think people as a whole will want it, public and private health insurance plans would benefit from it, and I think physicians would also benefit because, for one thing, it will motivate continuous quality improvement, and for another the doctor can use his rating as a marketing tool.

That suggests that physicians who adopt EHR now will put themselves in a superior strategic position.  They will be able to collect the maximum $40,000 incentive per practitioner over the five year period from 2011 to 2015; they will build up a body of evidence supporting the quality of their services; they will essentially shape the expectations of the market about health care quality in general; and their rankings will be front and center whenever someone needs a doctor.

July 6, 2009

EHR and Quality of Care

“Meaningful use of certified electronic health records” will become effectively mandatory for health care practitioners by 2015, if not before, primarily because of the savings in the cost of claims processing for third party payers – public and private – due to eliminating the handling and storage of paper documents.  Furthermore, digitizing patient data facilitates the extraction of key performance indicators with which to develop objective measures of physician performance, therapeutic effectiveness and quality of care.

Objective measurement of practitioner performance and health care quality, like any similar objective measurement, is a matter of sorting and counting, a task at which computers excel.  First, identify a condition, an event, or an outcome related to a desired goal.  Sort the occurrences of this condition, event, or outcome into meaningful categories and count them up.  Repeat as needed until all the relevant conditions, events and outcomes have been identified, sorted and counted, and then analyze the resulting numbers to see which ones move together, or in opposite directions, or are causally related.  The resulting collection of statistics and heuristics can be used to guide decision making to control costs and improve quality.

For example, consider a group of patients who present with respiratory symptoms, some of whom are smokers.  One could extract from this the following statistics:

  • Total Patients with Respiratory Symptoms
  • Smokers with Respiratory Symptoms
  • PerCent of Smokers to Total Patients with Respiratory Symptoms
  • Additional variants on the above broken down by available demographics
    • Gender
    • Occupation
    • Ethnicity
    • Age

One can count and categorize in the same way the times the physician offers smoking cessation counseling, which measures the practitioner’s response to this condition.  The set of this and similar statistics can be collected and published in a physician scorecard that compares his achievements with the average scores for his region, state, and the total country, and with benchmark goals set by Medicare or other third parties.

If all the patient data on which such statistics are to be based is on paper, the cost to produce useful quality of care reporting is astronomical.  While medical charts do contain discrete data that could be digitized using optical scanning, the most valuable information is contained in the practitioner’s progress notes, which are free-form text entries.  Much of this information could be made discrete, but to be contained on a pre-printed paper chart would require a form many pages long, little of which would actually be used in any patient encounter.

The benefit of an EHR system is that every diagnostic observation can be defined as a discrete element, and only appear in a chart when actually needed.  The EHR implementation process includes the creation or modification of templates that the practitioner uses during a patient encounter.  A template includes a comprehensive set of observations relevant to the type of examination and conditions encountered.  It also provides for free-text entry of additional information relevant for the patient.  Templates can be designed or modified, moreover, to insure that tasks or observations required for performance goals (as set by Medicare for example, or pay-for-performance incentive plans) are addressed in every relevant patient encounter, thus encouraging achievement of higher performance and quality scores.

EHR is crucial to health care reform.  The American Renewal and Reinvestment Act of 2009 (ARRA) sets forth incentives to be provided by Medicare to encourage “meaningful use of certified electronic health records” beginning in 2011.  This is intended to give health care practitioners ample time to select and implement a certified EHR system, which takes from nine months to two years depending on the size of the practice.  While some practitioners view the incentives themselves as “disappointing”, the benefits of EHR are ultimately so compelling that they cannot be swept under the rug.

Physicians who do not take action now run several risks.  For one, those who choose not to adopt EHR at all will be penalized with lower reimbursements from third party payers.  Those who respond by not accepting any insurance at all may experience a drop in the number of their patients, whose aversion to doing battle with insurers is at least as great as the doctors’.  On the other hand, those who wait until circumstances and their business partners finally force them to adopt an EHR will probably try to get it done as a rush job.  This will mean a truncated requirements specification and selection process, but a protracted implementation process as they struggle with a hurriedly selected product that is not a good fit.  It will be a far more costly and ultimately unsatisfactory experience as a result.

Doctors have expressed dissatisfaction that neither Medicare nor private insurers will pass much of their savings on to them.  They are being asked to invest tens of thousands of dollars in computer systems, but will be given back no more than 11% of the cost savings that will be realized by third party payers.  But practitioners should recognize that their own costs will be similarly impacted once they have converted to EHR.  Many tasks and functions currently required to handle paper patient charts will vanish with the adoption of an EHR, which can save the practice enough to recover the system cost in well under five years.

Still, it is fair to say that from the point of view of an investment decision, the incentives authorized in the ARRA beginning in 2011 are not strong enough by themselves to stimulate investment in EHR.  The most compelling benefits of EHR are not monetary.  But they are considerable.  Health care professionals should recognize that by not making the switch from paper charts to EHR they penalize themselves and the rest of us as well.

June 22, 2009

Why Physicians Resist EHR

Health care reform is a hot button topic.  No one seems to be exactly sure what it is, or how it will be achieved, but it is a priority of the Obama administration.  A cornerstone of reform is the application of computer technology to the creation, communication and maintenance of comprehensive patient health records.  To this end, the American Renewal and Reinvestment Act of 2009 (ARRA) authorized Medicare to pay incentives for “meaningful use of certified electronic health records”.  The incentives are intended to compensate for the cost of implementing EHR systems, which will save Medicare enormous sums by eliminating the handling of paper documents related to health claims.  Private insurers, too, would benefit from electronic patient records and can be expected to push for adoption of EHR by physicians who deal with them, so that eventually, EHR will be effectively mandatory for all US practitioners.

The health care community, however, is pushing back.  To begin with, neither Medicare nor the private insurers will be passing much of their savings on to the health care providers: no more than 11% by one recent estimate.  Despite the allowances specified in ARRA, the perception is that Medicare is allowing only a small percentage premium on billings for services on which compensation is already constrained, so it is unlikely that many practitioners will realize the maximum amounts authorized by the law.

Yet it seems to me from my discussions with physicians that neither the high (and uncertain) cost of EHR nor the inadequacy of incentives is the major cause of resistance.  Two other issues have far greater significance: integrating the system into the practice, and the potential for personnel displacement.

The integration problem is crucial, because if EHR cannot be integrated into the practice and its workflows, it will be abandoned.  The issue centers on the limitations of the man-machine interface, and the need for a user to focus attention on that rather than on communicating with the patient in an encounter situation.

Most people of my generation think nothing about using a computer, or a PDA for that matter, for a variety of tasks throughout our work day.  It has become almost second nature to us to use a mouse to point and click on a text field, and then type something in the field or select a value from a drop down list.  We can easily turn checkboxes on and off, select radio button options, and all the rest of the Xerox PARC functionality set that has been incorporated into both the Windows and Macintosh operating systems.  No big deal, right?

Well, maybe.  In a patient encounter, the keyboard and mouse of a standard PC setup is very distracting.  A more appropriate implementation is a tablet PC equipped with handwriting- and/or voice-recognition for entering text, on which the doctor can work much as he does with paper charts.  But paper is passive.  It just lies there while the practitioner does his examination and writes his results.  The computer responds to inputs, and the user must recognize that response and take appropriate action.  It can be a major distraction if the pattern of that computer dialog is incompatible with the user’s workflow preferences or the exigent circumstances..

Successful implementation of EHR requires three things.  First, the practice must select a software product that is designed or can be configured to be compatible with the way the practitioners work.  With three hundred or more products on the market, there must be at least one that meets this requirement, but if only a half dozen programs are considered, it is not likely that the best product will be found.  Second, a hardware platform must be selected that the users can feel comfortable with and that maximizes the benefits of the selected software.  Vendor input here is very helpful, but beware of “bundled” deals, as the bundled hardware may not be the best choice for the practice.  Third, adequate time must be spent on the specific configuration, including the design of templates that will be used in encounters so that the practitioner thinks about the patient, not the computer.  Altogether, that is a great deal of responsibility for a physician to take on while also trying to run a practice.  Add to that the perception of risk (sometimes based on prior experience) that the program still will prove too hard to use and will be abandoned anyway, and this becomes an almost insurmountable barrier to adopting EHR.

The other major obstacle is one I have not seen discussed in print, but it is always the elephant in the room.  That is the eventual displacement of one or more of the practitioner’s support staff by the automation of their functions.

A private practice, one that is not administered by a hospital or large clinic, requires a number of individuals to handle the business of the practice.  If this work is not outsourced, these may include (besides a nurse or physician’s assistant and a technician) a receptionist, a billing specialist, an insurance specialist, and possibly a medical transcriptionist.  With a staff that small, the employer/employee relationship is unavoidably close and personal.  There is no such thing as an impersonal business decision on human resources.  Every decision has personal consequences, and they are all acutely visible in the medical office.  If the practice decides to adopt an EHR, a significant proportion of work that is currently done by the practice staff will be taken over by the computer.  The usual business result of such “business process automation” is a lay-off of employees.  I believe that this is a major disincentive to investing in EHR.

Due diligence in selecting a software package involves not only matching the attributes of the software with the needs of the business, but also planning for the change in operating procedure that will be required.  This includes the shifting of functional responsibilities among employees, which can be like a game of musical chairs.  In the event that someone is left with essentially nothing to do, a transition plan can be developed and implemented early, including severance and assistance with job placement.  But the planning process can also identify new revenue opportunities with new functional responsibilities, such as on-line consultation, that may help to avoid any layoffs.

It seems clear at present that physicians who expect to retire by 2015 are not going to invest in EHR.  Physicians who are just starting out and don’t yet have their own practice are looking for positions with hospitals, clinics, or practices that already use EHR.  The vast majority of established practitioners who will be pressed into acquiring EHR need to be convinced that the risks are manageable and the intrinsic benefits, even without equitable incentives from third party payers, are sufficiently compelling.  And they need to start the acquisition process sooner rather than later, so that there is adequate time for due diligence.  The consequences of waiting until next year or the year after that are that eventually a deadline will be imposed that is too stringent, and as a result EHR will be an onerous burden instead of a valuable tool.

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