Future of Health IT: Trends and Scenarios

Forget Everything You Know About Healthcare Information Systems | healthsystemcio.com

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.

via healthsystemcio.com

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.

Cielo Clinic, Meaningful Use, and ACOs: My New Obsessions

As regular readers probably already know, I've been hiding out for several months now, getting up to speed in my new position as Chief Technology Officer at Cielo MedSolutions LLC. It's a natural next step for me, because Cielo is commercializing a University of Michigan Health System spinoff technology with which I was intimately involved in my previous position as a research informatician.

The spinoff technology was ClinfoTracker, a relatively simple and straightforward prompt and reminder system for primary care providers (PCPs). Now it has evolved into Cielo Clinic™, a clinical quality management system that can dramatically accelerate a practice's ability to participate in pay-for-performance (P4P) and pay-for-reporting (P4R) programs.  Participation in P4P/R programs translates directly into additional revenue for the practice, and it does so by facilitatinbetter quality care through delivery of evidence-based medicine in situ in the PCP-patient encounter.

There are other applications that support P4P/R participation, of course; some of these also provide alerts that are crude equivalents of Cielo Clinic's prompts and reminders. By "crude"

Cielo's compelling advantage stems from its focus on capturing and using clinical data rather than relying on billing data to drive its rules engine.  Rather than rely on ICD-9, the standard for coding problems in the US third-party payer world, Cielo Clinic employs ICPC and ENCODE, which are specifically designed for the primary care setting. Billing data has been shown to be unreliable for quality management in primary care.

Moreover, Cielo Clinic tracks clinician's response to the prompts. This ensures that, for example, if a physician has already advised a patient to undergo a colonoscopy based on a prompt driven by current clinical guidelines for colorectal cancer screening, and the patient refused, that prompt will not reappear for one year (or at a longer or shorter interval of the clinician's choosing, based on their knowledge of the patient).

We've been working on a new product that will soon become manifest in the marketplace, focused in part on the obvious buzzword of the day: Meaningful Use (MU), the benchmark the HITECH Act will use with its implications for direct patient care providers of $44K in incentives to adopt health IT.

However, we see HITECH and MU as blips on the strategic radar. The real opportunity -- and challenge -- in primary care health IT is in the development of Accountable Care Organizations (ACOs).

Lisa Bielamowicz, MD, Managing Director with the Health Care Advisory Board, the research division of The Advisory Board Company (ABC), recently posted a video entitled Keys to Success With Accountable Care Organizations on the MedPulse Business of Medicine newsletter from Medscape (free membership required to access). It's an 8-minute video that gives some good insights into how PCPs, their local hospitals, and the specialist practitioners with whom they collaborate can work together to improve patient care while reducing costs under the aegis of ACOs.