While continuing to poke around on the HealthSystemCIO site today (thanks to the Clinical Groupware Collaborative for the pointer, BTW), I came across a very insightful piece from Dan Morreale on the possibility that stand-alone EHRs may be obsolete.
Without a doubt, EHRs play a vital role within our traditional healthcare delivery model, characterized by independent physician practices and well-defined care delivery systems. As the pace of change has accelerated, however, we have to question how well the EHR — as a stand-alone information silo lacking longitudinal context — is able to handle the demands of coordinated delivery models. It’s time to forget and rethink the model.
Essentially, the problem with existing EHRs is that they are a) hospital-centric, and b) payment-oriented.
Hospital centricity means they are targeted at the large enterprise rather than small businesses like most primary care practices and IPAs). An enterprise can impose software on their employees. A small business must have systems that their staff (especially clinicians) find useful, and most EHRs aren't especially useful to primary care providers (PCPs) in the patient encounter.
Nor were they designed to be -- I'm not roasting the EMR community for designing to the requirements of their target market. A PCP's information requirements are very different from those of the specialist or hospitalist dealing with a patient in the hospital for (in most cases) a previously diagnosed condition with a pre-existing plan of care. PCPs deal with often-nebulous complaints that may take more than one visit to pin down into a definitive diagnosis.
Moreover, care planning for the ambulatory patient, especially those with multiple serious chronic conditions, must take many more factors into account than the in-patient setting. The patient's home- and community-based informal and paraprofessional support network must be taken into account. Those traditional EHRs that capture such information, and not all do, may nonetheless fail to provide timely access to it.
The traditional EMR's payment orientation is apparent in an information model that uses ICD-9 for diagnoses and CPT for procedures. These are fine for the in-patient world, but don't capture enough clinical detail for the PCP's purposes, especially with respect to nebulous issues and less-than-certain diagnoses that will take time and more visits to clarify.
Emerging multidisciplinary models of care offer the promise of higher quality for patients and reduced costs for the healthcare industry. These new approaches – including patient-centered medical home (PCMH) and accountable care organizations (ACOs) – harness the power of collaboration among primary care providers, specialists, hospitals, health systems, payers and patients to deliver focused, effective and coordinated care.
To fulfill their promise, however, these models require a different toolset than traditionally has been available to the healthcare market. EHRs, while evidence of technological progress in the industry, were designed to support a provider- and hospital-centric approach to care. As such, they are not fully equipped to catapult the industry towards the collaborative strategy preferred today. ACOs, PMHCs and other approaches will rely upon a platform that facilitates collaboration beyond the enterprise and across the community to achieve multidisciplinary care coordination.
In many ways, the initiatives mentioned in the last paragraph are more important to the PCP than Meaningful Use as defined in the HITECH incentives. ACOs and PCMHs have the potential to provide the right kind of incentive for PCPs to adopt health IT. The only thing missing from that long-term picture is a comprehensive, groupware-oriented IT system tailored to the PCP's requirements.