Recently I accompanied my 84-year-old dad to his geriatrician appointment. My dad is fortunate to have an experienced, caring, compulsive primary care physician to manage his congestive heart failure and other age-related chronic medical problems. This routine encounter included the usual outpatient clinic workflow: vital signs documented and medications reviewed on check-in; a short physician interview to update complaints, symptoms, and concerns; a physical exam; and a brief discussion about a plan of care based on the encounter data. This traditional workflow was disrupted by data-entry demands of the hospital-based EHR at every point—from vital signs to plan of care. It was as if the providers had 2 simultaneous and competing visits: one with my dad and one with the EHR. At one point while staring at the computer screen, his doctor said, “I hate this thing.”
Shouldn’t EHRs be facilitating patient care?
Meaningful Use should be driving EHRs to better help providers take care of patients, right?
Two weeks ago Diana outlined the Meaningful Use Stage 3 (MU3) objectives and Dr. John Halamka also reviewed MU3 requirements in a recent geekdoctor blogspot. Both write-ups explained that MU3 has direct Eligible Provider (EP) requirements, including ePrescribing, clinical decision support (CDS), and computerized order entry (CPOE). In addition, providers must ensure patient engagement and interoperability EHR functionality. In his blog on MU3, Dr. Halamka notes that EHR certification by the Office of the National Coordinator for HIT (ONCHIT) will include additional EHR functionality beyond MU3 requirements. Are CPOE and ePrescibing helping providers and patients at the point of care?
On April 6, 2015, Medscape published an interview between Dr. John Mandrola and physician, author, and educator Abraham Verghese who has a deep interest in bedside medicine.1 Mid-interview Dr. Mandrola asks Dr. Verghese if he sees a way to make EMRs useful and not distract from patient care. Dr. Verghese replied:
“Charles Dickens said that every book operates around one great lie. Every character is suffering from one big delusion. The great lie is that the medical record is about the medical record. The medical record is about billing.”
Is the purpose of your EHR more for billing capture than patient care?
The Center for Medicare and Medicaid Services (CMS), ONCHIT, and the U. S. Congress that passed the HITECH Act part of the American Recovery and Reinvestment Act of 2009 and the Patient Protection and Affordable Care Act of 2010 are investing in EHRs and health IT as part of a value-based health care delivery model. As Terry notes in previous blog posts, value is quality divided by cost for a population of patients. Fee for service, which counts encounters and procedures, is going away. In the new age of value-based purchasing, billing will reflect patient population health. EHRs will capture discrete individual patient data that rolls up to document the quality and cost of care for your patient population. While providers may care for patients one by one, each provider will be measured and reimbursed on the population health performance. CMS, the big payer, oversees MU3 requirements and, no surprise, MU supports population health management with required reporting to disease registries, immunization modules, and ePrescribing, which generate population-level data.
The Institute for Health Technology and Transformation (iHT2) provides an excellent overview of healthcare technology and population health management. iHT2 notes that “providers must improve data integrity, increase the amount of discrete data, and use standardized measures” in order to make population health management work. Isn’t that the rub for providers at the point of care? As you care for an individual patient at a clinic visit it is hard to collect discrete data. Can your history of present illness ever be adequately captured in a dropdown?
Where is population health management headed?
Population health management is made possible by the aggregation of large amounts of health data from labs, CPOE, ICD 9 or 10 coding, medication lists, vaccines, vital signs, etc. Health-system-generated data is enhanced by vast amounts of patient-generated data from mobile devices. Future population health management will be continuous and highly automated with data analysis that creates patient subpopulations based on high risk for certain events. Chronic disease management and preventive care services may be delivered to patients who are actively engaged in the health delivery system and also to patients who are not engaged, using non-clinic-based services. Continuous monitoring and interventions will happen between episodic patient clinic encounters or clinic visits.
EHRs are currently an important point-of-care, discrete data-entry source feeding the aggregate data pool for population health management. In the future most of the data providers now collect at the point of care may be available through mobile devices (e.g., vital signs, cardiac and pulmonary assessment, fluid status) no clinic visit required. Providers may use the EHR as a data supplier to manage patient outliers either in person or remotely. The clinic workflow will be centered not on the collection of data, but rather on using data to deliver interventions, and EHRs will give you data and clinical decision support instead of demanding data entry.
In the words of Imagine Dragons:
“I’m waking up, I feel it in my bones
Enough to make my systems blow
Welcome to the new age, to the new age
Welcome to the new age, to the new age”
- Verghese, A. “Hope for Hands-on Medicine in the EMR Era.” Medscape. Apr 06, 2015.
Dugan Maddux, MD, FACP, is the Vice President for CKD Initiatives for FMC-NA. Before her foray into the business side of medicine, Dr. Maddux spent 18 years practicing nephrology in Danville, Virginia. During this time, she and her husband, Dr. Frank Maddux, developed a nephrology-focused Electronic Health Record. She and Frank also developed Voice Expeditions, which features the Nephrology Oral History project, a collection of interviews of the early dialysis pioneers.