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Beyond Meaningful Use

Carrie Vaughan, for HealthLeaders Magazine, February 4, 2010
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Better outcomes require better data. Technology can help the healthcare industry achieve better outcomes and cost savings, but only if providers incorporate decision-support tools and a coordinated approach to delivering care.

Most electronic health records are a silhouette. Organizations can recognize the patient and, by exchanging medical records, can even help expedite or improve care—but to improve outcomes, the healthcare industry needs to add detail and context. Only then can the silhouette be transformed into a true portrait, in which all of the pertinent information is up-to-date and accurate and can be effectively used, says James L. Holly, MD, CEO of Southeast Texas Medical Associates in Beaumont, TX. "When I go to the hospital, I see about 15 to 25 patients, and I want the following information: blood pressure, pulse, pulse oximetry, how much oxygen they are on, respiratory rate, temperature, maximum temperature in the past 24 hours, bowel movement, diet, appetite, and activity."

Currently, Holly has to write down that information or manually enter it into an EHR. The industry needs to get to a place "where the hospital gathers that information in a structured fashion, so that our EHR can point and say 'pick up this,'" he says. "In two seconds that information is displayed and made part of that day's record, and you can compare it graphically with the past three days or five days."

That "full-portrait" EHR would update new diagnoses and laboratory tests, and reconcile medications so there is a current, up-to-date picture of the patient's health status that can be integrated into a discharge summary with follow-up instructions for the patient or nursing home. "It doesn't come cheaply, and comes with a lot of work," says Holly.

The federal government is investing $20 billion in healthcare information technology from the American Recovery and Reinvestment Act of 2009 to improve healthcare quality while lowering the cost of delivery. Providers have a whole list of technologies that they need to implement and use effectively by 2015 to capture their share of the incentive payments, or they will start to incur penalties.

Based on the 2011 meaningful use criteria defined by the Centers for Medicare & Medicaid Services on December 30, 2009, for example, providers have to improve quality, safety, efficiency, and reduce health disparities by using computerized physician order entry, e-prescribing, and maintaining an active medication list and up-to-date problem list of current and active diagnoses. Providers will also have to engage patients and families by providing patients with an electronic copy of their health information, including diagnostic test results, medication lists, and problem lists, and to improve care coordination by having the capability to exchange key clinical information among care providers. In addition, providers will have to improve population health management by having the capability to submit electronic data to immunization registries and public health agencies—all while ensuring adequate privacy and security protection for personal health information created or maintained in the EHR.

That is just a snapshot of the technologies organizations need to have in place for the 2011 guidelines. Each year the thresholds and expectations will increase. The proposed rule only defined the 2011 meaningful use criteria, but it did provide insight into where organizations will need to be by 2015. For instance, organizations should be able to achieve minimum levels of performance on national quality, safety, and efficiency measures; use clinical decision support for national high-priority conditions; give patients access to self-management tools and comprehensive health data; and not only capture data in electronic formats, but also be able to exchange both transmission and receipt of that data in an increasingly structured format. The goal by 2015 is to have a patient-centric, interoperable health information exchange across provider organizations regardless of providers' business affiliations or EHR platform.

It's a tall order with a lot of moving parts. But to improve outcomes beyond the meaningful use guidelines, senior leaders can't lose sight of what the technology will have to be capable of years from now. Healthcare providers will need to be able to process in a timely manner all of the data being generated to provide the type of clinical decision support and coordinated care that physicians want and patients and payers will demand.

EHRs are difficult to implement, and more often than not the use of the data becomes secondary, says Jack Kowitt, chief information officer for Parkland Health and Hospital System in Dallas. There are three elements organizations should focus on when converting to an EHR: the implementation, the process improvement built into implementation, and the use of the data that comes from implementation, he explains. "But each of those adds time and cost to the implementation. You could add 12 to 24 months, so process improvement gets downgraded and really designing how to use the data gets downgraded," he says. "The plan to use the data is lower in a lot of these projects than you'd think."

Better outcomes requires coordinated care
Senior leaders should already be thinking beyond their four walls to how the data will be used to coordinate care in the future and what impact that will have on their relationship with other care providers.

"Five years from now, organizations will need to be able to manage patients across a broad continuum of services," says Michael Dowling, president and CEO at North Shore-Long Island Jewish Health System in New York.

Healthcare organizations will need to figure out a way to align physicians, hospitals, and all of the other providers—long-term care facilities, hospice, and ambulatory sites. Technology will play an essential role, he says. But organizations will also need a very robust commitment on how to utilize the IT to promote quality and outcomes, he says.

That's one of the reasons North Shore is investing $400 million in EHRs to connect providers in its community. Managing entire episodes of care across providers and environments is difficult in the current environment, when patient information is in fragments, says Michael Oppenheim, MD, North Shore's chief medical information officer.

So North Shore is offering to subsidize up to 85% of the software and operating costs of an EHR system for roughly 7,000 affiliated physicians. The 14-hospital health system is giving physicians two different subsidy options. Doctors who choose the connected model will receive a 50% subsidy (as permitted by law) for all of the costs associated with buying, operating, and using an EHR from Allscripts for five years. In turn, the physician agrees to allow the exchange of clinical data. For example, "if a patient comes to the emergency department, the ED physician would be able to pull pertinent information from the community physician's office EHR," says John Bosco, chief information officer at North Shore-LIJ. Then, once the patient is discharged from the hospital, "we can push a discharge report or summary to the affiliated physician's EHR system," he explains.

The integrated model provides an 85% subsidy that includes all of the above, plus physicians would agree to collaborate on the development of and follow clinical practice parameters or care guides that are built into the system and based on nationally recognized standards of care for certain disease states like diabetes and congestive heart failure.

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