Accountable Care Workgroup, Meaningful Use Workgroup, Quality Measures Workgroup, Information

Accountable Care Workgroup, Meaningful Use Workgroup, Quality Measures Workgroup, Information Exchange Workgroup

Oral Remarks

My perspective is based on 25 years of being in private practice, quality improvement chair, and physician hospital organization medical director. Rolling out IT solutions in my own practice, coordinating the production of hundreds of order sets with our Kettering Network EMR, and directing network-wide process improvement projects has shown me not only the hurdles and difficulties in meeting a budget, but also how little most of these activities have to do with providing high quality care.

Let me walk through typical day in my life because it illustrates, as a microcosm, the scope of the issues and why current information solutions are so inadequate. My first patient is in my office at 7 o'clock AM. He is there since his primary care doctor referred him to me. He has no idea why he was sent to me except he was told that he needed to see me. His referral information was only partially filled out by the family doctor and our office did not call them to verify the information. I start asking him about his health and review his medications. It turns out that he has been having a lot of problems with his hands and has been told it is gout but never had a real diagnosis of this before. In reviewing with him he has been on steroids at different times for flares. I assume that he was there due to the difficulty in his hands since he has no other complaint; thus I work on a better diagnosis and possibly a better definitive therapy. He is on several hypertensive medications that all can cause gout. He has never collected a 24-hour urine for uric acid. Unfortunately the lab office is not open yet and since we did not order his lab tests we cannot review all his labs results. The family doctor's office is not open yet either for us to get his most recent information. I nevertheless come up with my working diagnosis and action plan. And the patient is on his way.

Next I'm off to the hospital, since I am on the ICU service. Overnight a gentleman was admitted for pneumonia, respiratory failure and sepsis. He does not normally come to our hospital system so I do not have easy access to his records. During his history and physical he informs me that he cannot be in the hospital long since he has an appointment with a thoracic surgeon for his esophageal cancer. Our service had appropriately placed him on the ICU community acquired pneumonia order set. I then start searching on-line for his records from the other institutions, having to go through screen after screen of data items that have no clinical importance. Finally, I get to the operative report but it just states the plan is to wait for pathology. After more searching I finally find what I think is the relevant path report and it turns out not to be cancer at all, but Barrett's esophagus with metaplasia, which is non-cancerous. The patient does not believe me, so I have to print out the report and show him. He does not understand why he was being sent to a surgeon. The referral is cancelled.

I have more admissions and the next patient has in their past medical history a diagnosis of periodic hypokalemic paralysis (PHP). I'm excited since this is a rare condition. I go through the last two hospital stays and the diagnosis was brought forward last time. I reviewed the discharge summary and there was no mention of this diagnosis anywhere. After further investigation, on our EMR when you type in hypokalemia the first choice offered is always PHP and on the second line is hypokalemia. So it was a missed click. I correct (I think) the record in the hospital EMR, but I have no idea which other databases and what other care this has influenced.

I go on to my next patient. She is on a ventilator and sedated, with no family. The medication reconciliation was performed by nursing and just brought forward by the admitting resident. She is on a multitude of medications, all with possible drug-drug interactions. I see that she on Lovenox, a low molecular weight heparin, and Xarelto, a blood thinner, as well. She is anemic and her abdomen is firm. Could she be bleeding internally? CAT scans of her head and abdomen are ordered and all comes back fine. We finally get hold of the family and they said that she was on those medications last year for a knee replacement and has not been on them recently. We call her family doctor and she recites yet another different list of medications! We asked the family to bring in all her medications and they even have more from other physicians as well.

My office calls me and informs me that the very first patient of the day, whose gout I worked up so nicely was not referred over to me for gout but rather for a colonoscopy due to his occult-blood positive stool!

Next I move on to supervise our internal medicine residents at their clinic. We have a facility set up in which one half of the building is a Federally Qualified Health Clinic (FQHC) and the other half is the specialty clinic, not part of the FQHC. Patients often go from the primary-care-based FQHC to the specialty clinic. Two years ago the FQHC half installed a putatively“top rated” CCHIT EMR. Unfortunately it does not interface with a single practice or hospital network. My residents are across the hallway in the specialist clinic where we have the complete array of medical and surgical specialists; this last week the clinic installed another putatively“top rated” CCHIT EMR. As one comes to expect, of course this does not interface with the FQHC EMR! Now we literally are leaning across the divider and asking the primary care physician, “Why are we seeing your patient?”

Every care venue has a putatively wonderful, certified EMR and they are all connected via some number of HIEs. Each EMR/HIE provides a different, partial, and often-conflicting snapshot of each patient’s care. This applies not only to every care provider (each of which must synthesize their own “guess” as to what this patient has based on the data they “happen” to see from all these sources) but also to every patient who is seeking to contribute to making his or her health better. Every physician a patient sees has a different portal for them to get information about themselves. They have the PCP portal, their urologist portal, orthopedic portal, hospital portal, cardiologist portal, pulmonologist portal. Each has a different user name and password. All with a different story to tell, in a form virtually unintelligible to most patients and perpetuating all the silos of misinformation which the patient has no chance of reconciling.

The myriad Meaningful Use CCHIT certified EMRs and HIEs with which I interacted in this part of one day are all from what are putatively considered to be top notch national vendors, but unfortunately every EMR is just a silo of technology. Even within a single EMR, not only does it lack much data, but it lacks virtually any ability to turn that data into information. EMRs, designed for billing and the creation of claims attachments, understand little or nothing about what they are doing. They move what are essentially documents from place to place so providers can look at them at every point and, one-by-one, for each interaction or visit, gives them some transient new meaning. They are designed to run practices and hospitals and clinics – NOT patients. They provide a fragmented view of each patient’s health, hoping that each provider can put something back together again.

Classically I was trained that form follows function and function follows form – clearly in this case the improper form of the current Health IT infrastructure creates dysfunction. Following the form-to-function model, the solution to this is a different electronic architectural solution: a patient-centric model. To have any chance of moving to value-based, rather than volume-based care, what is needed is a health information model organized around making sense of all known information about each individual for the purpose of all of that individual’s providers and the individuals themselves – not an information model organized around venues or building a “dumpster” of venue-centric data. As circumstances are now, the Meaningful Use criteria drive every venue to a venue-centric, document-based model. And we have all learned that just connecting the data silos together does not drive quality but rather creates dumpsters of suspect data that in the end seem to do nothing but hamper data mining and efficiency.

In our practice we have specialized in consultative internal medicine for over 25 years, bridging patients from acute outpatients to inpatients and then back home. We provide coordination of difficult complex patients that require perioperative evaluation, follow-up testing and titration of medications. We did this before computerization, then with EMRs and now with the Internet. In doing so we have been able to maintain our high quality with solid metrics; however, the issues of coordination of care, researching patients’ past medical and surgical histories, and doing the right thing for each individual is more difficult now than it has ever been. Part of this is the inadequate and cumbersome technologies, part is the increasing complexity of health care itself – but suffice it to say it remains difficult and cumbersome.

In striving to improve care, communities have developed and launched health information exchanges and have been supported by private and public funds. Uniformly they have failed to live up to the promise. They have data downloaded but are rarely used in any real transformative care. In addition they do not have all the data about patient care and if they did they do not provide information that is actionable to drive quality for the individual let alone the community. Going to outpatient electronic medical records again, even if two different practices have the same EMR vendor they do not communicate in anything even close to seamless. To do any disease management is fraught with problems. Yes they are CCHIT certified and yes they can send CCD documents. But to do this in any scale is impossible. Every vendor seems to work hard to make sure that you can only talk to yourself; giving useful electronic information to a patient or to a requesting external system requires many dollars and, as near as I can tell, often an act of God. What should be automatic is made so difficult, most just give up…other than supporting data dumpsters that take long periods to set up and that are, in the end, not useful.

All my interactions with existing MU certified EMR vendor’s reveals that they are not motivated to improve things about patients – just to sell more of their stand-alone systems. They ignore the issues, and then are very slow, since it is not in their best interest for their data to get to somewhere where it might be shown to be more valuable than in their EMR. Further, it seems their architecture limits, hampers, and constrains their products. In my heart I think they all realize they have a Potemkin village – behind the façade of “caring for patients” they are really just still delivering environments to care for practices. While this was a fine business decision in a volume-based care world, it does not work when the payment and medical systems are finally aligned to care for patients – a new patient-centric infrastructure must be the foundation of any new value-based health reorganization.

Notes to follow