Beyond Meaningful Use

Johnson says the hospital is still struggling to pull meaning out of small statistical samples, however. Middlesex has 14,000 inpatient visits per year. But once that is sorted down for congestive heart failure, the number of cases drops to 300.

"The great thing about the stimulus plan, getting meaningful use defined and then by investing in the systems, is that it will allow us to collect information and share it in a way that is far better than what we have been able to do to determine what is evidence-based medicine," says Johnson.

Better outcomes requires better data
North Shore-LIJ expects to have the first capability to start aggregating data from its hospitals, 1,200 employed physicians, and the community physicians' EHRs by this summer. But filtering through the "glut of information to find value at the end of day will be difficult," acknowledges Oppenheim.

To effectively manage all of this data, "we need some control over terminology—for example a sodium and a serum sodium is the same observation," he says. Organizations will also need a master patient index to recognize the same patient across the different systems. "Otherwise," Oppenheim says, "I can't reliably move my information from practice A to B to C."

Patient identity is challenging enough just within the health system, says Bosco. Merging the data from the community physicians' and hospitals' EHRs is one of the most difficult aspects of managing care across a continuum, he says, which is why North Shore-LIJ has a team working on just patient ID and developing a community number that can be assigned to each patient. "We are trying to design things now that won't leave us a mess and a huge volume of data down the road that we can't report on," he says.

Because creating a national patient ID system is not part of the HITECH Act, organizations will need to develop their own systems for managing patient identity across the continuum of providers. "The industry doesn't have the organizational structure to deal with information exchange," says Johnson. "Who is responsible to maintain the integrity of the patient registration system?"

Middlesex is employing staff members to validate every patient who is admitted and triple checking that the patient is linked across the health system. Now Middlesex, which is the only hospital in Middlesex County, will have to do that for the 120 physician practices in the area, Johnson says, noting that it will still be easier for them than larger health systems with multiple hospitals and ancillary groups.

"Without some kind of national ID, we are going to spend millions of dollars to develop local patient ID solutions and then one day throw all of that away and settle on some kind of national solution," says Bosco.

Beyond those challenges, the technology needs to present more comprehensive summaries about the patient, says Oppenheim. One of the main limiting factors for better clinical decision support is generating enough data about the patient that is in a manipulatable format.

The burden rests on physicians to enter data into specific fields in the order set that can be used to generate reports. Unless the information that physicians are being asked to enter is clinically relevant to the decision they are trying to make at the moment, it can be very frustrating for them to pause and enter additional patient information.

Better outcomes requires transparency
The biggest roadblock to improving outcomes may not be the capability of the technology but rather the cultural change that is required to use it effectively. Trans- parency is a key component to leveraging the power of electronics to change the way providers care for patients, says Holly.

SETMA plans to publicly report via its Web site deindentified data on how it is performing on quality metrics on a monthly basis. It's already posting data on patients' previsit evaluations, like whether the patient smokes or had a flu shot or an elevated blood pressure reading, so physicians can better manage the health of their patients.