By David C. Kibbe
In a post here three weeks ago, I explained that I am engaging physician audiences in a conversation about participatory medicine, using a talk and presentation entitled "Confessions of a Physician EMR Champion.”
I “confess” my own misplaced hope in the EMR movement, and that I’m finally embracing the reality that most investments in health IT have not met expectations.
My broad message is that the key lesson of this failure has been that adoption of health IT without understanding the fundamental interactions between people, business process, and technology wastes both human and economic capital.
To be successful, the adoption of health IT by physicians, nurses, and staff must extend communication and health data exchange beyond their practices and bill payers to include the patient and family members, the patient’s team of health and wellness professionals, and ancillary service providers such as pharmacists and lab technicians in the community.
Health IT must be able to support coordination and continuity of care, as well as accountability for doing the right things for patients. I now realize most EMRs are not sufficient to this task, and I was wrong to think they would evolve in this direction.
Most EMRs are software applications that document care with digital chart notes, and collect information on fee-for-service items so that this information can be sent off to health plans and Medicare for payment. This is basic accounting inside the practice that often leads to better reimbursement.
But it is not accountability.
There is nothing transformational or disruptive about EMRs because they have been designed to meet the functions and features of a status quo business model — not the collaborative and participatory capabilities required of the business models of the future health system.
In this next installment of the conversation, I’d like to suggest some specific capabilities that health IT ought to empower doctors and health care teams to perform on behalf of, and in collaboration with, their patients.
I’m suggesting that we go back to the drawing board and design health IT that is truly a good fit for doctors and patients in a system that rewards quality, safety, and efficiency of care while working to keep people healthy, instead of simply adding up the charges when they’re sick.
In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, released the "Joint Principles of the Patient-Centered Medical Home."
In this document they state the characteristics of the Patient Centered Medical Home are:
* Personal Relationships * Team Approach * Comprehensive Care * Coordination of Care * Quality and Safety * Expanded Access to Care * Added Value and Cost Efficiency
These are highly desirable characteristics of not just primary care, but of health care and its delivery at many levels and in many settings. Thinking about how to design health care organizations and how to train health professionals with these characteristics in mind is a good place to start. And in my opinion, it should be obvious.
What is not currently obvious in late 2008 are the best ways in which health IT should be deployed to help reach the characteristics of the connected medical home desired by patients, providers, and payers, and summarized above. It is especially not clear that "one size fits all" when trying to match health IT products and services with the desired characteristics, or how to do so in a manner that is affordable and sustainable across a variety of practice types, large and small, urban and rural, and so on.
The class of health IT software applications known as electronic medical records, or EMRs, may be helpful to some kinds of practices in achieving some of these characteristics. But, as many medical practices and communities around the country have become painfully aware, the mere presence or deployment of EMR software from a commercial vendor, even if “certified,” does not guarantee continuity and coordination of care, nor even communication among providers in the same neighborhood.
I suggest that a wiser approach is to describe the capabilities that health IT ought to provide or enhance if a medical practice is to become a successful medical home in any setting and under most circumstances.
The list below of Empowering Health IT for the Connected Medical Home is not intended to be complete or exclusive. Over time it may expand or be modified according to the evolution of both the concept of the medical home and the technologies themselves. This flexibility is probably a virtue in a time of constant change. However, I believe this is a reasonable description of the health IT that will empower medical practices to become medical homes in the near future.
So, let me go ahead and define Empowering Health IT as computer hardware, software, and related technology that provides or enhances:
1) The capability to collect, store, manage, and exchange relevant personal health data and information electronically, such that this information is accessible at the times and places where clinical decisions will be or are likely to be made, and such that this accessibility improves the patients’ continuity of care experience between and among various settings of care and different episodes of care. Accessibility of personal health information and continuity of the care experience are linked benefits of health IT that confers the capability of computerized data storage and transmission of the relevant information to the point of care. It almost goes without saying that this capability must include adequate privacy protections.
2) The capability of providers, patients, and other members of a person’s health care team to communicate with each other and amongst themselves in the processes of care delivery and care management, such that a team approach that assures coordination, quality, and safety of care is encouraged, and that access to care is increasingly available to patients both online and in person. Coordination and continuity are only possible if data and information can be affordably and easily transferred. This does not mean face-to-face visits are always the only, or the best, way to provide continuity of care.
3) The capability of providers and their practices to collect, store, measure, and report on the processes and outcomes of individual and population performance and quality of care, and that can be used to inform both providers, patients, and payers through reports and graphic displays on the success of efforts to make quality improvements in attaining evidence-based levels of care, especially for chronic conditions and diseases. Collecting and communicating health data without inclusion of analytics is a like a horse with three legs.
4) The capability of providers and their practices to engage in decision support for evidence-based treatments and tests, and to do this at or close to the point of care, as well as in a manner that is understandable and directly useful to patients and consumers through outreach reminders and alerts, education, and online tools and methods. Dispersed decision support web services are an economical way to do this is the age of information. Knowledge should be wherever the patient is located.
5) The capability of consumers and patients to be informed and increasingly literate about their health and their medical conditions, and to appropriately self-manage with monitoring and coaching from providers. Health IT that successfully provides or improves this capability will remove barriers and impediments to data, information, knowledge and tools that can contribute to a person meeting his or her wellness or health promotion goals, and will put in place bridges that close the gaps in collaboration and coordination between the medical home provider and patients. Participatory Medicine requires this capability not as an afterthought to care, but an integral and designed aspect of care.
What I’ve done is to suggest that five fairly specific areas of capability are important for health IT to be empowering and disruptive: 1) electronic data and information collection and access; 2) communications among providers and patients; 3) clinical decision support; 4) population quality, performance, and cost reporting ; and 5) consumer/patient education and self-management.
Many different products already on the market can be helpful in assembling this set of capabilities, including some EMRs, PHRs, e-Prescribing software products, web portals and secure messaging services. Population registries are also examples of health IT that can provide or improve these capabilities.
But it is also the case that emerging and completely new types of health IT platforms can do the job, e.g. community health information exchange systems and state-wide clinical integration web portals. These new products may be especially attractive if they permit components to be added in plug-and-play fashion so that medical practices can grow their health IT in an organic, affordable fashion.
Some web portals currently limited to patient services may evolve in the direction of shared health IT tools that engage both physicians and patients in a participatory web of shared online services, in effect a new species of “electronic health records.” Exactly how we get there is not as important to me as the affordability, usefulness, and value designed into these new products and services. I think we have to know what we as citizens want before we can help vendors design it and bring it to market.
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I’ve moved my comments over here to Part 2, from the original or Part 1 of the “Confessions” blog, to continue the conversation.
First, let me answer Christine’s question about how I altered my TN after the first blog post, and comments from readers. I changed it quite a bit, actually. The responses to the “Confessions” have been much more numerous and spirited than I ever expected. I seem to have hit a nerve out there, and so I changed my talk to give the audience more time to discuss alternatives to EMRs, and invited audience members to tell their stories about the uses of non-EMR, low cost but high impact health IT in their practices. It was well received.
Responding to Cyril’s post about the AMCIS product, I did go to the web site, and will add this to my bookmarks of companies providing innovative solutions that offer health IT platforms for communication, coordination and continuity of care. Re-thinking this space is very important. I’m going to read the White Paper later today. Many thanks for the information.
Kind regards, DCK
Dear Lauren: Are you old enough to remember the rapid progression of features and functions that added on to Netscape, in the early days of the web? For a while, it was just text and pictures. Then there were plug-ins for audio, and video. Bookmarks were added. And so on…
This kind of viral growth of functionality to a platform is highly unusual, but devastatingly disruptive and exciting when it happens. Consumers really love it. The same thing is happening now with Facebook and other social networking platforms.
In contrast, most EMRs and EHRs are versioned client-server, database management systems that have not kept up with the pace of change, and strictly limit the new features and functions that users can “plug-in.”
Kind regards, DCK
I enjoyed reading this post and comments. I see a lot that can be improved upon in the healthcare system through EHRS adoption and optimization. One thing to remember is that the EHR is a work in progress. Hopefully an organization does not “go live” with an EHRS and not work to make it better and enhance its functionality as it gets to know the system better.
Patient web portals will also help to enhance the patient-based healthcare, and I would like to see more developed functionality in this area. Some I’ve seen go beyond the clinical summary and appointment scheduling to provide e-visit functionality, online patient questionnaires and even inpatient hospital interaction.
This is a very rational approach presented by Dr. Kibbe and I do not disagree. When I designed the product I spoke about in the prior blog I used two basic thoughts or priniciples to create a finished product.
First I wanted something that everyone could use so I stuck to the “Keep it simple, stupid” principle. It is very easy for a professional with any specialty interest to create something that is so specific that it becomes complex for the general group of professionals and not useful for all. That, to me, was the problem with the VA system. While it is an excellent tool it is so complex that you almost need a degree in specific training to implement and utilize the system.
Second. healthcare is a very complex product but it basically comes down to an action between two primary participants; the patient and the physician. I recognize that often results in acts by other professionals or individuals, but when properly provided the subsequent efforts are coordinated by the patient’s primary physician or care team.
As a result, the requirements set forth respecting data collection, availability and access become essential as described by Dr. Kibbe. While I do ascribe to “best practices” I do not believe in an automatic or robotic response to treatment of a specific patient and hence feel that including a logarithm that results in use this treatment protocol does not necessarily belong in the system.
As far as analysis is concerned, the ability to collect codified data (diagnostic, procedural and therapeutic) by sex, age and other qualifiers is inherently present. Perhaps even more revealing, the system allows analysis at the individual physician level. It is all well and good to say that there is a 10% risk of a complication or a failure but what happens if a particular physician has that specific complication or failure occurring 50% of the time? or never in his/her practice? Today, there is little chance of collecting that type of data and when would it be meaningful? In the case of hospitals, the same can be said although there is such data available today.
Analysis for the purpose of a nationawide population is a hit or miss proposition today. With an EMR that collects data through a coordinated approach across all specialties and service providers would be advantageous but it is a product of the the system and it is not the purpose.
As to patient participation, I fully ascribe that the better educated the patient is with respect to their disease process and the expected progression and current status the better the outcome. I do not accept the anectdotal accounts of individual interventions and their individual results as positive evidence of quality care or even good care. As to access by the patient and control, I would place it as an absolute must that the patient have full access to the data and be allowed to review it as frequently as they desire. The ability to notify (test results,prescription refills, etc) may or may not be needed and I would not rule that out but I would question what is essential in this regard where it becomes simply a marketing different bell or whistle.
Some might disagree, but I do believe that an EMR will create better quality care and a more economical system.
Dear SR: Many thanks for your thoughtful comment. We need people to articulate their wants and needs from health care providers the way you have done, and en masse. You’re right: health IT isn’t the solution. But it can be enabling for virtually all of the services you mention. Your banking system analogy makes perfect sense. My health data should be wherever I am located and can get to a computer or cell phone.
I love the story of your father and his health blog! My mother is 88 years old, and emails almost everyday, gets reminders from her online pharmacy for refills. And SMS ought to be one of the options for getting lab ressults, of course!
Would other readers be willing to offer their own preferences for participatory medicine, and tell their stories? Please do! Regards, DCK
Health Care consumers and patients have a wide range of interests, needs and values that vary across our lifespans and circumstances and hopefully there will be many different tools, products and services provided to both providers and users of health care.
For example, my 70 y/o retired father is the head of a neighborhood wellness program with over 3,000 people and maintained a family blog during my mom’s cancer treatment but doesn’t own a cell phone and would rarely change physicians despite differences in quality. I am rarely ill and yet expect SMS alerts if a lab test is done and want my clinical records to link with my nike tracker in my shoe as well as apps on my Iphone.
I envision a system similar to the financial sector (bad example right now perhaps) where you are able to move your information from clinician to clinician (online bank statements = EMR) supplement that with information gathered via other ancillary providers (investment account at E-trade) take all of that information into my PHR (without entering most of the data so it is similar to downloading into Quicken)adding in some personal data (from my nike+ sensor and mobile apps that track my diet and yoga classes) and generate reports (like turbo tax) to share with some of my providers.
In the banking system transactions happen offline via a debit card so I really want a smart card (lifemed card) loaded with my current problem list, meds, demographic information so that I never ever again have to fill out a clipboard. I also don’t care who “owns” the data I care that I can move it to where I need it to be in real time and it is safe, secure and presented in a way that I can understand.
I don’t want to have to go to medical school on the side, spend hours filtering through social networking sites to determine if someone works for a drug company. Are the outcomes any better if I do? I expect health care providers to provide me with the best links to information (Information Therapy) and if I need social support provide me with the best offline resources to real people as well as online.
I also don’t want to shop for the highest quality lowest cost providers like I am purchasing a Tv since I will rarely be in a position to make a change based on that information. If my spouse has a heart attack or a parent has cancer I expect all providers to give us the highest quality care but it would be great if clinical alerts were sent to me as well as my providers. (this would stress my parents out though if they got them) I don’t want to be placed in the position of changing a hospital or care giver when a spouse is having a HA because I just goggle searched the hospitals infection rate. (I might use quality metrics to buy insurance or for an elective procedure but question what some metrics measure? High quality of providers or just those with high income patients?)
Technology is not the “solution” to our health care un-system (as Europe is able to accomplish better outcomes without EMR’s or PHR’s) but the commitment to include patients in their own health care management that technology allows us is a reflection of that shift. Information is just the first step. It has to be transformed into knowledge and knowledge into behavior change and that requires mass customization of the IT tools and surrounding services.
There is more to health care then transactions of data and at its core healing takes place in the context of a series of relationships and those are based on trust not technology.
(FYI full disclosure – I actually implement EMR’s for a living, serve on State quality and patient safety boards; National HIT committees and I am a strong consumer advocate. I am very well aware of the best practices in HIT as well as the very real limitations of HIT)
Dear etaiota: Yes, in part 3 I’ll address the consumer/patient/citizen’s interests and desirable health IT features, with some data to support the idea that the demand for Participatory Medicine is already present. But you can help. As a patient, what do you want your doctor or medical practice to be able to offer you as services that are health IT-dependent? Regards, DCK
I agree with you here. Back when I was an engineer, one of the crucial concepts to understand was that you couldn’t fix a problem until you found the cause. Throwing random (and really expensive!) “solutions” like EMRs at the health care mess are not going to do a bit of good. France manages to provide excellent quality care at less expense without EMRs, “medical homes”, “decision tools”, “nurse practitioners”, etc. Their docs are arranged in solo and small group practices and paid on a fee for service basis. What are they doing right? What does Germany and the UK do right, what do they do wrong? There is data available. The right solution may be an expensive high-tech one or it may not. We need to know before we go throwing money and regulations at the mess that is American health care.
I enjoy reading your posts, Dr. Kibbe. This post seems to end with a teaser. How do you propose we measure what we as citizens want? Perhaps that’s the 60 million dollar question – or – Part III of your series?