The next big thing on the strategic conveyor belt of system transformation is coordination of care, that particular ability to get different treatment settings and the people within them to communicate well and work together as they manage shared patients and defined populations. Trustees will have to consider how to invest sensibly in connecting clinicians and funneling the information they need to produce good results in collaboration.
The industry is replete with information technology solutions for the coming coordination challenge, often calling for a costly, complex mechanism for health information exchange on top of already costly electronic health record systems, which health care organizations either have in place or in the works to meet federal implementation timetables linked to incentive payments.
The end game for care coordination likely will require a regional care continuum of physician, hospital and post-acute options that only HIE can tie together successfully. But before boards are talked into new and extra IT for care coordination, they should be aware that a lot of the basic capacity may be lurking inside their current, incentive-worthy EHRs. "Irrespective of the supplier, the value of an EHR from a coordination-of-care view has been highly underrated in the context of the overall reason for investing," says Leslie Clonch, vice president and chief information officer of University Health Care System, Augusta, Ga.
"Most physicians, and maybe hospitals, view the EHR as a nice transactional tool that turns out nice reports and gives them rapid, legible information on the desktop," says Arnold Wagner Jr., M.D., chief medical information officer of NorthShore University HealthSystem, Evanston, Ill. "But it is way more than that." An EHR spanning the total reach of a health care system can engineer provider and patient communication, education pathways and the potential to arm clinicians with insightful analysis, he says.
Some organizations get it, but "the vast population [of providers] doesn't quite get it yet," Wagner says. "If you're not steeped in this [more comprehensive capacity], it's very easy to say, 'I have a deficiency here that I'm not addressing; here comes a solution provider that suggests they can fix it.' Well, you may be able to do that already if you just understood and configured properly."
The federal government's requirements for meaningful use of EHRs is meant to be a starting point. The bigger picture always has been around "not just automating the paper record, but eventually getting to the point of evaluating populations to determine, 'Did I do what I set out to do?'" says Karen Knecht, R.N., a partner with Encore Health Resources.
Ample ability to effect coordination underlies many of those requirements. But to reap that power, "you have to have that vision while you're putting the system in," she says. For many enterprises, "in the effort and passion and all the energy to get the EHR in to meet these timelines, that got lost."
When it comes to the basics of buying and using information systems in clinical settings, "it's not a matter of choosing projects; the projects choose us," says Audrius Polikaitis, CIO of University of Illinois Hospital & Health Sciences System, Chicago.
Besides HITECH's three stages of meaningful use guidelines, the switch to the ICD-10 coding system requires improvements in data creation, standardization and retrieval. In addition, the Affordable Care Act has induced the industry to prepare for such priorities as value-based payment, bundles of services under fixed payment, and accountability for the health care needs of predefined rosters of patients. IT vendors have a similar project list, "because we as users of their products demand that they have these capabilities built in," says Polikaitis.
But just what are these capabilities? Knecht sees many of the HITECH requirements for EHRs as the technological assists necessary to organize and inform teams of providers — for example, the ability to manage medications and to assemble and present a list of a patient's problems. "If you can't get these fundamentals in, then you don't know who your patient is," she says. The first stage of the federal program has focused on building into IT a lot of previously nonexistent coordination capabilities, she says.
In a standard certified EHR, identifying a patient's current and active diagnoses and the associated problems is a key starting point. A well-documented problem list "can be very efficiently coordinated with a variety of folks who participate in the right setting of care based upon that problem list," Clonch says.
If an organization looks at the problem list as a way to coordinate the care of, say, diabetes patients, instead of merely a function to attest to for the incentive, "all of a sudden you do look at this in a very different way, and it doesn't become a technical issue but really a process piece" to facilitate teamwork, Knecht says. But during implementation, clinicians have to be educated on the use and importance of the problem list, and to be diligent in compiling it so it's usable to any team trying to coordinate its efforts.
It's the same with medication reconciliation and adherence to quality metrics, she says. Instead of just proving an implemented EHR can get through those actions, health care organizations should go the distance in generating effective new processes that can be applied to any disease condition. The benefits to care coordination can span the care episode: use an EHR to lay out problems at the start, facilitate communication throughout, reconcile hospital-dispensed medications with what patients are taking at home and inform the critical discharge process automatically.
The upshot is being able to execute priorities better for tracking patient treatment and providing best practices in care, Clonch says. The discharge process, for example, had been hit-or-miss in the past, underappreciated as a touch point for avoiding readmissions. Now details needed by patient, attending provider and follow-up provider "are all much more efficiently gathered, much more comprehensively integrated and much more easily interpreted based on the role in that care process," he says.
Providers still have more organizational challenges to sort out, Knecht says, but "the technology is really starting to grease the skids, even force the issue of, 'Hey, you've got the information; I need that information; can I get access?'"
While recent government programs may have accelerated these cross-communication aspects, to some degree an EHR always has been more than an a computerized patient record. When the University of Illinois introduced its then-novel EHR to the teaching hospital and outpatient facilities more than a dozen years ago, its role as a communication tool ranked right up with record retrieval as a plus, and those two benefits have blended together since then, Polikaitis says. "It's become the record, and the benefits that the record provides. It's just become part of everybody's daily life around here."
It's both pull and push. Caregivers seeking to read a patient's chart or see results can pull that data from the record, but another component of the system is the integrated clinical inbox where information is pushed to clinicians, often by colleagues, he says. Inboxes are expected to be reviewed regularly, prompted by messages saying, "Act in the best interests of your patients: Check your inbox daily."
Doctors at University Health Care System in Augusta see its recently implemented EHR as a "much more efficient way to do things," Clonch says. "They're able to see results online, they're able to communicate back and forth with [other] physicians. It's just a very effective vehicle from an efficiency and care coordination point of view." At NorthShore, explicit communication is not necessary in many cases, because "the transfer of information takes place as a byproduct of what you're doing," says Wagner. "The information is just there; I don't [need to] make a request for it."
Basics in hand, the next level of focus is to adapt IT capability to the new emphasis on caring for populations based on their disease-specific needs and other pertinent factors, such as how severely the disease affects patient health and whatever other ailments complicate matters. To anticipate these developments, "the EHR enables us to capture additional information which helps [us] understand the health status of a patient at any point," Clonch says.
When the patient appears at some future date, "we know more about that patient than we did before, simply because we're collecting more and simply because we can manage more information through these electronic tools than we could before," he says. The scope of that fact-gathering has gone beyond clinical history to include social history and home factors, such as whether there are people to care for a patient once outside the care continuum of University Health Care System. That can influence decisions around moving a patient to another setting.
Effective use of the information for broader purposes requires an analytical software engine to mine EHR and other data fed into a separate database called a data warehouse, which may or may not be included in a vendor's implementation, experts say. At NorthShore, which operates an EHR from Epic Systems Corp., a non-Epic data warehouse integrates data from the Epic clinical system and a financial information system for process analysis, "ultimately feeding back into the clinical record for improvement," CMIO Wagner says.
That level of IT also allows health care systems to keep tabs on patients by their severity of illness, disease state and other health status through the use of registries. In the past, these tools grouped and kept track of people with cancer, heart disease or diabetes typically through reporting by clinicians who had to send reports in batches, eventually amassing a worthwhile number of cases. But today's EHRs can do that automatically through simple computer setups, says John Glaser, chief executive of the health services business at Siemens Healthcare and previously a pioneer of EHR development in hospitals for two decades. "A registry is just the plumbing of the database to determine and sort patients by their conditions," he says. "It's not a separate thing anymore. It is just a view into the infrastructure."
Providers are brainstorming to figure out how the technology can support coordination, as long as the innate capabilities for a certain use are put forward and well-implemented, Knecht says. A performance improvement plan in advance can isolate the specific IT capabilities that need to be activated. Some physician practices have used written coordination-of-care guidelines, such as those from the American Diabetes Association, as a framework to work with IT vendors or staff to automate the guidelines, create targeted alerts for, say, only high-risk incoming patients, and know the recommended treatments.
A form of close coordination in hospitals and physician offices is the "huddle group," where a team of variously skilled professionals starts the day by deciding what each has to do for the patients they share. At OakBend Medical Center, Richmond, Texas, such a team can be seen pulling up charts from the EHR on a big screen and examining them together to determine proper courses of action — Do they have the right resources available? Are they moving a patient? Do they have to engage a certain doctor? — "and it's all driven by the fact that they can share the data," says CEO Joseph Freudenberger.
Nurses take their electronic record stations into patient rooms, and that mobile access has paved the way for full-time bedside nursing availability at OakBend. The only warm chairs at nursing stations are those of the charge nurse, unit secretary, monitor tech and doctors coming and going, Freudenberger says. "We now have our nurses deployed out on the floor all shift long." A process has evolved around it: Nurses have personal phones and numbers for anyone who needs to reach them, not only other clinicians but each nurse's assigned patients. No call buttons are linked to the deserted nursing station.
Organizations that focus on the regulatory requirements of EHR implementation, and complain about products that are "imperfect," miss the chance to get the most out of these coordination assets, Knecht says. "Sometimes in this industry what happens is, the noise of what doesn't work right is overpowering the fact that we actually have a very powerful tool in place."
John Morrissey is a freelance writer in Mount Prospect, Ill.
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