Beyond Meaningful Use

In addition, the community doctors would report their performance data related to those parameters back to North Shore-LIJ on a monthly basis so that the health system can aggregate that data to determine the impact the program is having on the community. For example, North Shore-LIJ would have data on a population of diabetes patients in the region, so it could identify ways to improve outcomes by better managing the health of those patients.

"If we can measure and manage quality and do things like reduce unnecessary testing and delays when a patient comes into our ED or improve their transition of care out of hospital into the physician office, that is really what will impact quality and cost," says Bosco. "If anything happens on payment reform like bundled payments for disease management, we'll have the tools in place that are necessary to report and bill out those entire episodes of care," he says.

North Shore-LIJ is addressing one of the obstacles to the realization of an interoperable healthcare system: the cost. Funding was cited as the biggest roadblock to health information exchanges, according to the HealthLeaders Media Industry Survey 2010 (see page 26), which surveyed just over 100 senior healthcare technology executives in fall 2009. At the time, 37.76% of technology executives cited funding as the biggest obstacle, followed by interoperability (29.59%), lack of standards (17.35%), and security (8.16%).

"None of this comes cheaply," says Dowling, acknowledging that a single hospital would be hard-pressed to subsidize EHRs for its medical staff. North Shore-LIJ's reported revenue is in the $5 billion range. "But I don't see how we can survive in the future if we don't do this," he says.

"This is about changing culture to meet the needs of patients across the continuum. We have all of these components, so we need to connect the dots," says Dowling. "In the future, we will be paid based on how we manage care across continuum—from the time the patient meets with the physician in his office, to the hospital, to the outpatient site, to the long-term care facility."

But organizations can't wait for the government to pay for transforming healthcare, says Holly, an outspoken advocate of clinical IT. This 26-member multispecialty practice has been using an EHR for 11 years and has invested about $5 million in clinical IT.

"We are not wealthy," says Holly. The industry has to morph and change because it's the right thing to do to improve patient care. "We have created a lot of ugly interfaces and then made them pretty."

For the past year, SETMA has been working to transform care to a patient-centered medical home model. It has incorporated 14 data points and four action steps into its EHR from the Physician Consortium for Performance Improvement to transition patients from the inpatient setting or emergency room to another setting, such as a rehabilitation or long-term care facility. It has also added electronic patient management tools to its Web site and launched a follow-up call program. All of SETMA's hospitalized patients will receive a phone call the day after their discharge to ask if they have their follow-up appointments scheduled and medications filled, if they know what to take, how they are feeling, and if they have any new or worsening problems.

In addition, SETMA is developing a program to enable providers and specialists outside of its network to have secure access to patient information from its EHR. "If they are seeing a patient, they can import it to their record," Holly says. "For referrals it is going to be incredible, because we'll give an access code for them to get data and they can download it and be on their way—it will be a one-minute process." SETMA is not charging anyone for the service for the first three years; after that time the providers who use the service would share in the cost.

Connecting EHRs so providers can access robust information across facilities is one of the first steps organizations should take to improve outcomes, but the real value—and even bigger challenge—will be using the data that all of these technology systems generate to provide physicians and clinicians relevant information at a point in the care delivery process when it can impact their decisions and ultimately improve care. Providing physicians timely clinical decision support is the most exciting and challenging part, says Oppenheim.

Better outcomes requires evidence-based decision support
CMS acknowledged the importance of decision-support tools in getting value from EHRs. It increased the number of clinical decision-support rules required for the 2011 meaningful use guidelines from one, which was originally recommended by the HIT Policy Committee, to five decision-support rules relevant to a specialty or high clinical priority, including for diagnostic test ordering.

Decision support may be in its infancy, but organizations should already be looking beyond alerts that remind physicians to comply with quality measures for congestive heart failure or to offer smoking-cessation materials. Organizations, for example, will need a system that can tell physicians the patient has a specific gene, which means they should prescribe a lower dose of Tylenol for the best outcome. Or that doing a CT scan did not provide the type of information that the physician is seeking, based on similar cases from the past, so the physician can avoid doing an ineffectual test and choose a different diagnostic or treatment option.

Unfortunately, the evidence-based medicine in play right now to back decision-support tools isn't all that great. Like many organizations, Middlesex Hospital, which has been using CPOE since 2008, has been using clinical pathways to reduce the variance in how it delivers care. These pathways, developed by its physician leaders, were created from medical literature and national standards on the best protocols for treating congestive heart failure, for instance.

For the past two years, the 185-staffed bed hospital has been loading those orders—roughly 4.5 million per year—into a business intelligence system to evaluate the effectiveness of those pathways. The hospital reviews reports about every six months and communicates those results to the physicians who maintain the patient pathways and order sets. "We are starting to take the outcomes of our patients and look at them compared to what we were doing last year and the year before," says Ludwig Johnson, vice president of information services. "Oftentimes you may be in for congestive heart failure, but you may also have diabetes or asthma," he says.

Providers will need to look at this data in a much more sophisticated way to improve outcomes. Middlesex plans to start tracking outcomes and correlating it back to the version of pathways and order sets the physician used.

For example, Middlesex will be able to look at all of its pneumonia cases, sort by physician, and see the variance from both a cost and clinical outcome perspective. "We can create these profiling reports and bring it to physicians and physician leadership to bring those variances closer together," he says. The variance may be due to physician preference or training, but the reports will help align physicians and improve quality based on the data.

The hospital doesn't just plan to foster a discussion about ordering practices, either. It will incorporate that data to create more robust evidence-based alerts than what is currently being used. Physicians would still have the authority to override the alert, but they will have to provide an explanation much like they do today.