Carrie Vaughan, for HealthLeaders Magazine, February 4, 2010

Better outcomes require better data. Technology can help the healthcare industry achieve better outcomes and cost savings, but only if providers incorporate decision-support tools and a coordinated approach to delivering care.

Most electronic health records are a silhouette. Organizations can recognize the patient and, by exchanging medical records, can even help expedite or improve care—but to improve outcomes, the healthcare industry needs to add detail and context. Only then can the silhouette be transformed into a true portrait, in which all of the pertinent information is up-to-date and accurate and can be effectively used, says James L. Holly, MD, CEO of Southeast Texas Medical Associates in Beaumont, TX. "When I go to the hospital, I see about 15 to 25 patients, and I want the following information: blood pressure, pulse, pulse oximetry, how much oxygen they are on, respiratory rate, temperature, maximum temperature in the past 24 hours, bowel movement, diet, appetite, and activity."

Currently, Holly has to write down that information or manually enter it into an EHR. The industry needs to get to a place "where the hospital gathers that information in a structured fashion, so that our EHR can point and say 'pick up this,'" he says. "In two seconds that information is displayed and made part of that day's record, and you can compare it graphically with the past three days or five days."

That "full-portrait" EHR would update new diagnoses and laboratory tests, and reconcile medications so there is a current, up-to-date picture of the patient's health status that can be integrated into a discharge summary with follow-up instructions for the patient or nursing home. "It doesn't come cheaply, and comes with a lot of work," says Holly.

The federal government is investing $20 billion in healthcare information technology from the American Recovery and Reinvestment Act of 2009 to improve healthcare quality while lowering the cost of delivery. Providers have a whole list of technologies that they need to implement and use effectively by 2015 to capture their share of the incentive payments, or they will start to incur penalties.

Based on the 2011 meaningful use criteria defined by the Centers for Medicare & Medicaid Services on December 30, 2009, for example, providers have to improve quality, safety, efficiency, and reduce health disparities by using computerized physician order entry, e-prescribing, and maintaining an active medication list and up-to-date problem list of current and active diagnoses. Providers will also have to engage patients and families by providing patients with an electronic copy of their health information, including diagnostic test results, medication lists, and problem lists, and to improve care coordination by having the capability to exchange key clinical information among care providers. In addition, providers will have to improve population health management by having the capability to submit electronic data to immunization registries and public health agencies—all while ensuring adequate privacy and security protection for personal health information created or maintained in the EHR.

That is just a snapshot of the technologies organizations need to have in place for the 2011 guidelines. Each year the thresholds and expectations will increase. The proposed rule only defined the 2011 meaningful use criteria, but it did provide insight into where organizations will need to be by 2015. For instance, organizations should be able to achieve minimum levels of performance on national quality, safety, and efficiency measures; use clinical decision support for national high-priority conditions; give patients access to self-management tools and comprehensive health data; and not only capture data in electronic formats, but also be able to exchange both transmission and receipt of that data in an increasingly structured format. The goal by 2015 is to have a patient-centric, interoperable health information exchange across provider organizations regardless of providers' business affiliations or EHR platform.

It's a tall order with a lot of moving parts. But to improve outcomes beyond the meaningful use guidelines, senior leaders can't lose sight of what the technology will have to be capable of years from now. Healthcare providers will need to be able to process in a timely manner all of the data being generated to provide the type of clinical decision support and coordinated care that physicians want and patients and payers will demand.

EHRs are difficult to implement, and more often than not the use of the data becomes secondary, says Jack Kowitt, chief information officer for Parkland Health and Hospital System in Dallas. There are three elements organizations should focus on when converting to an EHR: the implementation, the process improvement built into implementation, and the use of the data that comes from implementation, he explains. "But each of those adds time and cost to the implementation. You could add 12 to 24 months, so process improvement gets downgraded and really designing how to use the data gets downgraded," he says. "The plan to use the data is lower in a lot of these projects than you'd think."

Better outcomes requires coordinated care

Senior leaders should already be thinking beyond their four walls to how the data will be used to coordinate care in the future and what impact that will have on their relationship with other care providers.

"Five years from now, organizations will need to be able to manage patients across a broad continuum of services," says Michael Dowling, president and CEO at North Shore-Long Island Jewish Health System in New York.

Healthcare organizations will need to figure out a way to align physicians, hospitals, and all of the other providers—long-term care facilities, hospice, and ambulatory sites. Technology will play an essential role, he says. But organizations will also need a very robust commitment on how to utilize the IT to promote quality and outcomes, he says.

That's one of the reasons North Shore is investing $400 million in EHRs to connect providers in its community. Managing entire episodes of care across providers and environments is difficult in the current environment, when patient information is in fragments, says Michael Oppenheim, MD, North Shore's chief medical information officer.

So North Shore is offering to subsidize up to 85% of the software and operating costs of an EHR system for roughly 7,000 affiliated physicians. The 14-hospital health system is giving physicians two different subsidy options. Doctors who choose the connected model will receive a 50% subsidy (as permitted by law) for all of the costs associated with buying, operating, and using an EHR from Allscripts for five years. In turn, the physician agrees to allow the exchange of clinical data. For example, "if a patient comes to the emergency department, the ED physician would be able to pull pertinent information from the community physician's office EHR," says John Bosco, chief information officer at North Shore-LIJ. Then, once the patient is discharged from the hospital, "we can push a discharge report or summary to the affiliated physician's EHR system," he explains.

The integrated model provides an 85% subsidy that includes all of the above, plus physicians would agree to collaborate on the development of and follow clinical practice parameters or care guides that are built into the system and based on nationally recognized standards of care for certain disease states like diabetes and congestive heart failure.

In addition, the community doctors would report their performance data related to those parameters back to North Shore-LIJ on a monthly basis so that the health system can aggregate that data to determine the impact the program is having on the community. For example, North Shore-LIJ would have data on a population of diabetes patients in the region, so it could identify ways to improve outcomes by better managing the health of those patients.

"If we can measure and manage quality and do things like reduce unnecessary testing and delays when a patient comes into our ED or improve their transition of care out of hospital into the physician office, that is really what will impact quality and cost," says Bosco. "If anything happens on payment reform like bundled payments for disease management, we'll have the tools in place that are necessary to report and bill out those entire episodes of care," he says.

North Shore-LIJ is addressing one of the obstacles to the realization of an interoperable healthcare system: the cost. Funding was cited as the biggest roadblock to health information exchanges, according to the HealthLeaders Media Industry Survey 2010 (see page 26), which surveyed just over 100 senior healthcare technology executives in fall 2009. At the time, 37.76% of technology executives cited funding as the biggest obstacle, followed by interoperability (29.59%), lack of standards (17.35%), and security (8.16%).

"None of this comes cheaply," says Dowling, acknowledging that a single hospital would be hard-pressed to subsidize EHRs for its medical staff. North Shore-LIJ's reported revenue is in the $5 billion range. "But I don't see how we can survive in the future if we don't do this," he says.

"This is about changing culture to meet the needs of patients across the continuum. We have all of these components, so we need to connect the dots," says Dowling. "In the future, we will be paid based on how we manage care across continuum—from the time the patient meets with the physician in his office, to the hospital, to the outpatient site, to the long-term care facility."

But organizations can't wait for the government to pay for transforming healthcare, says Holly, an outspoken advocate of clinical IT. This 26-member multispecialty practice has been using an EHR for 11 years and has invested about $5 million in clinical IT.

"We are not wealthy," says Holly. The industry has to morph and change because it's the right thing to do to improve patient care. "We have created a lot of ugly interfaces and then made them pretty."

For the past year, SETMA has been working to transform care to a patient-centered medical home model. It has incorporated 14 data points and four action steps into its EHR from the Physician Consortium for Performance Improvement to transition patients from the inpatient setting or emergency room to another setting, such as a rehabilitation or long-term care facility. It has also added electronic patient management tools to its Web site and launched a follow-up call program. All of SETMA's hospitalized patients will receive a phone call the day after their discharge to ask if they have their follow-up appointments scheduled and medications filled, if they know what to take, how they are feeling, and if they have any new or worsening problems.

In addition, SETMA is developing a program to enable providers and specialists outside of its network to have secure access to patient information from its EHR. "If they are seeing a patient, they can import it to their record," Holly says. "For referrals it is going to be incredible, because we'll give an access code for them to get data and they can download it and be on their way—it will be a one-minute process." SETMA is not charging anyone for the service for the first three years; after that time the providers who use the service would share in the cost.

Connecting EHRs so providers can access robust information across facilities is one of the first steps organizations should take to improve outcomes, but the real value—and even bigger challenge—will be using the data that all of these technology systems generate to provide physicians and clinicians relevant information at a point in the care delivery process when it can impact their decisions and ultimately improve care. Providing physicians timely clinical decision support is the most exciting and challenging part, says Oppenheim.

Better outcomes requires evidence-based decision support

CMS acknowledged the importance of decision-support tools in getting value from EHRs. It increased the number of clinical decision-support rules required for the 2011 meaningful use guidelines from one, which was originally recommended by the HIT Policy Committee, to five decision-support rules relevant to a specialty or high clinical priority, including for diagnostic test ordering.

Decision support may be in its infancy, but organizations should already be looking beyond alerts that remind physicians to comply with quality measures for congestive heart failure or to offer smoking-cessation materials. Organizations, for example, will need a system that can tell physicians the patient has a specific gene, which means they should prescribe a lower dose of Tylenol for the best outcome. Or that doing a CT scan did not provide the type of information that the physician is seeking, based on similar cases from the past, so the physician can avoid doing an ineffectual test and choose a different diagnostic or treatment option.

Unfortunately, the evidence-based medicine in play right now to back decision-support tools isn't all that great. Like many organizations, Middlesex Hospital, which has been using CPOE since 2008, has been using clinical pathways to reduce the variance in how it delivers care. These pathways, developed by its physician leaders, were created from medical literature and national standards on the best protocols for treating congestive heart failure, for instance.

For the past two years, the 185-staffed bed hospital has been loading those orders—roughly 4.5 million per year—into a business intelligence system to evaluate the effectiveness of those pathways. The hospital reviews reports about every six months and communicates those results to the physicians who maintain the patient pathways and order sets. "We are starting to take the outcomes of our patients and look at them compared to what we were doing last year and the year before," says Ludwig Johnson, vice president of information services. "Oftentimes you may be in for congestive heart failure, but you may also have diabetes or asthma," he says.

Providers will need to look at this data in a much more sophisticated way to improve outcomes. Middlesex plans to start tracking outcomes and correlating it back to the version of pathways and order sets the physician used.

For example, Middlesex will be able to look at all of its pneumonia cases, sort by physician, and see the variance from both a cost and clinical outcome perspective. "We can create these profiling reports and bring it to physicians and physician leadership to bring those variances closer together," he says. The variance may be due to physician preference or training, but the reports will help align physicians and improve quality based on the data.

The hospital doesn't just plan to foster a discussion about ordering practices, either. It will incorporate that data to create more robust evidence-based alerts than what is currently being used. Physicians would still have the authority to override the alert, but they will have to provide an explanation much like they do today. 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. SETMA has invested more than $300,000 in data-mining software that it has embedded into the EHR to monitor nationally recognized quality metrics and HEDIS measures, which are used by more than 90% of health insurance plans to demonstrate that their members are receiving quality care. The medical group can now audit its performance on these measures on a daily basis. Next, it will use evidence-based medicine to define quality goals and then use the data-mining software to ensure their treatment protocols are being followed and used appropriately. Lastly, SETMA plans to use the data to change physician and patient behavior to yield better outcomes.

SETMA's public reporting, disease management, and EHR measurement tools are available at no charge at www.jameslhollymd.com.

Electronic health records need to enable providers to evaluate themselves, be able to audit providers who are not inclined to improve themselves, and report those findings to external agencies and the public, Holly says. That way, "people can start picking providers based on those who are giving the best quality of care based on measurement sets that reflect quality of care in various settings."

Physicians are still concerned about sharing all of this data, acknowledges Simon E. Prince, MD, president of the medical staff society for North Shore University Hospital in Manhasset, NY, and partner in a five-member physician practice. Prince's medical group will be one of the first to take advantage of North Shore-LIJ's 85% subsidy for EHRs. "We can get a state-of-the-art EHR at a rock bottom price and qualify for stimulus money," he says. His group opted for the larger subsidy, because "it is only a matter of time until this data is out there anyway," he adds.

Easing physicians' fears about how the data will be used and conveying the real motivation behind North Shore-LIJ's plan is a huge challenge, says Dowling. The health system has to break down physicians' hesitancy about working closely with hospitals. "There is a little bit of ambivalence sometimes about what the real motivation behind this is," he says. "'Is the hospital trying to do something to us?' rather than thinking 'What is it doing with us?'"

To get physicians onboard with the plan, Dowling emphasizes that the investment is about quality, not technology. "Organizations have to look at this as one way to share information, use clinical protocols, and be more transparent so that the industry can demonstrate better outcomes and improve care for patients."

Carrie Vaughan is senior technology editor for HealthLeaders Media. She may be contacted at cvaughan@healthleadersmedia.com.