Uncategorized

Are Today’s EMRs Up to the Job?

RS Head Shot 1 This post is a bit different from most of the policy points, institutional cases and reports of technical innovations that I’ve been reading on THCB in the past months. I want to pose the above Question to the readers of this blog, since many of you are uniquely positioned help answer it in your comments. And I have a hope that your responses to this Question will help nuance the technical and policy debate over EMR adoption.

First, let’s unpack the Question:

1. THE JOB. In the past several years, a number of public and private initiatives, most recently ABMS’s Improving Performance in Practice (a project with which I am affiliated) and NCQA’s Patient Centered Medical Home,  have been making fitful progress toward a new post-reform model of primary care:  patient-centered, accessible, care-coordinating, population-focused, prepared, proactive, and the rest. These collaboratives and demonstration projects have all stressed the importance of computerized ‘registry functions’ as the foundation for these progressive capabilities. One, the Health Disparities Collaboratives run by HRSA, went so far as to commission a registry program and provide it free to participating clinics.

A key hope and assumption of many of those leading this work has been that once practices have implemented EMRs, and once they have standardized their protocols and coding sufficiently, they will be able to use their EMRs to fully support the new, population-based model of care. Practices that have attempted to do this have faced daunting challenges. Many practices have ended up using both an EMR and a registry, with all of the duplication and rework that this implies.

2. The EMRs. Fifteen years ago, while working as a QI and informatics trainer, I had occasion to take a first-hand look at the database architecture of one of the popular outpatient EMR programs of that era. (It is still a very popular program, and will here remain nameless.) What I found became a cautionary example for my classes when I explained relational database principles: The database contained a table for patient data, a related table for medication data, and another for patient problems. But, probably for reasons of speed and simplicity, there was no ‘gerund’ table that would link medications to problems. While that data structure worked fine for displaying a list of patients, their problems and medications on a single screen, it was impossible to use the datatbase to answer such population-level queries as ‘which patients are currently prescribed aspirin for CVD prophylaxis?’ And no amount of massaging or exporting or data-warehousing could make it answer such a question – the required relational information was simply missing. Alas, my career path since those days has not put me back in the engine room of that or other EMR systems, so I am unable to say whether this was a fluke, or is now typical of EMR design.The upshot: If these kinds of lacunae still infest the architecture of today’s EMR products, then it would seem that widespread adoption of today’s EMRs will consign much vital clinical data to a kind of ‘black hole’ out of which it will be impossible build the queries and reports that are needed to support the kind of flexible, improvement-oriented, population-based primary care that we increasingly seem to need.

Finally, the question again, refined: “Will the data architecture of any of today’s outpatient EMR programs allow their data to be used – either directly or following transfer to an offline data warehouse, by means either of built-in reports or third-party applications – to support population-based care of the kind described in the PCMH?”

I look forward to your responses and discussion in the days ahead. Since this may be a sensitive subject for some, please mention your affiliations if they are relevant to your response.

Richard Scoville, PhD, is an independent consultant specializing in healthcare quality improvement and performance measurement. He is an Adjunct Professor in the Department of Health Policy and Administration at the University of North Carolina at Chapel Hill where he teaches courses in healthcare quality improvement and informatics. He serves as an improvement advisor to the Institute for Healthcare Improvement, NICHQ, the Cincinnati Children’s Hospital Medical Center, and the Federal Health Resources and Services Administration on a range of collaborative improvement and systems design projects.

Livongo’s Post Ad Banner 728*90

Categories: Uncategorized

Tagged as: , , ,

23
Leave a Reply

23 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
15 Comment authors
New Updates to our Product CatalogueBalaclinicianEvan Earl Dussia, II, MDpropensity Recent comment authors
newest oldest most voted
New Updates to our Product Catalogue
Guest

of course like your website however you have to take a look at the spelling on several of your posts. Many of them are rife with spelling problems and I in finding it very bothersome to inform the reality however I will definitely come back again.

Bala
Guest
Bala

However the case, there will be a number of IT healthcare jobs that open up just to deal with all of the bugs that will happen if there is one big shift to EMRs. Most likely it will happen over time, according to each hospital’s budget. Regardless, it’s an exciting time to be an IT professional in the healthcare industry.

clinician
Guest
clinician

The clinicians in England understand…The HIT gear delivered by US companies was “not fit for purpose”. The National Health Service wasted boatloads of money that could otherwise have gone for medication and nurses.
People would say that it is pathetic that the Obama HIT gurus do not learn from history and the same could be said for the self-interested and self-proclaimed HIT gurus and do-gooders commenting on this blog.

Evan Earl Dussia, II, MD
Guest

Dear rbar, It is worse than that, you forgot the legal system. Whatever of the 4 possibilities you pick, you have to deal with Aunt Fleurie who comes in at the last minute and says, “These doctors don’t know what they are doing. They don’t do it like this where I come from. They are doing too much (or too little, you pick) we need to go see the local plaintiffs attorney and sue these docs and this hospital to the max.” What part of the final tab is due to “defensive medicine” and making sure that the clinician has… Read more »

rbar
Guest
rbar

Dr. Dussia – I am skeptical re. P4P because I think it is almost impossible to measure best performance with reasonable effort. I think that physicians should be reimbursed mainly with a base salary, and only partially (maybe 30%) with incentives (based on feedback by providers and patients and lastly, productivity in numbers of patients served). I gave some thought to your question: “What if your treatment plan had been dictated by an impersonal “evidence based protocol” and decisions were made by a committee based on the fact that “evidence” had determined that you were a “terminal” patient?” I think… Read more »

Evan Earl Dussia, II, MD
Guest

Mr. Brammer, This is just one of the daily decisions of clinicians. It is what we get paid to do. The McGlynn study is typical of institutional studies that try to pick out a plan for care to stamp on a population of patients. This is the typical way we teach. I know, I have been there. It does not reflect what happens at the bedside. What if your treatment plan had been dictated by an impersonal “evidence based protocol” and decisions were made by a committee based on the fact that “evidence” had determined that you were a “terminal”… Read more »

propensity
Guest
propensity

Hey experts, professors, and patent possessors: you are making medical care sickeningly more complex than it already is. Routine and habit are high priorities for patient care. The DOD US Army has found out the hard way:
http://www.usmedicine.com/article.cfm?articleID=1906&issueID=123

C Brammer
Guest
C Brammer

Dr Dussia – First off, i have tremendous respect for your work and the challenging situation you present. I don’t think P4P is the mechanism to address such an issue (nor is technology, for that matter). These are clearly societal conundrums -the payment system can only respond to, and reflect, the views of society. And from a personal level –as a formerly “terminal” lymphoma patient that finally convinced someone to do a BMT after being rejected from a leading cancer center– i can appreciate the complexity of such a situation. Meanwhile, the most frequently cited study in the history of… Read more »

Evan Earl Dussia, II, MD
Guest

Craig Brammer wrote, “Per my earlier post, the authors (providers) are increasingly compensated via payment reform models (e.g., P4P, gain-sharing). Financial incentives, in my view, should be oriented toward improving patient outcomes. Here is the case—an 85 year old lady with cancer everywhere. Her entire family has converged at her ICU bed. You are the clinician in charge. Which performance will you get top payment for (P4P): 1. You call a full-court press. The top of the line bed, top of the line medications, multiple consultations from the very best specialists and the absolute best nursing care to be found… Read more »

C Brammer
Guest
C Brammer

Dr Dussia writes, “The effort should not cost the authors of the clinical information any money. The time and effort are enough. In fact, I believe clinicians should be compensated for use of their DCAs by others with legitimate reasons for access to the author’s work product.” Per my earlier post, the authors (providers) are increasingly compensated via payment reform models (e.g., P4P, gain-sharing). Financial incentives, in my view, should be oriented toward improving patient outcomes. Managing data to improve outcomes –and demonstrate it to payers/purchaser– is the cost of business to receive the additional compensation. I’m of the opinion… Read more »

Evan Earl Dussia, II, MD FACOG
Guest

Dr. Sucher, Thanks for responding. I guess I don’t expect much from a surgeon from the South—because I am a surgeon from the South. 🙂 Nevertheless, just a couple of comments: Workflow is critical. Because your work product is a document of clinical activity (DCA), just like mine, any application that collects clinical information should accommodate your creation of the DCA and require no incremental workload. Validity is simple—you signed the DCA. The effort should not cost the authors of the clinical information any money. The time and effort are enough. In fact, I believe clinicians should be compensated for… Read more »

Alan Viars
Guest

When designing data models (database tables & relationships) it is good design to think about how the user will use the data and build to make those things easy. (Figure out the majority of your queries in the beginning, and design from there.)
-Alan

Alan Viars
Guest

MUMPS/Cache are “schema-less”. Schema-less models have their place, but I agree with the author that the lack or relational database capability is a component of EHR complexity and degrades EHR fitfulness. MUMPS/Cache are very obscure and have a very limited development community. More modern approaches are needed.
-Alan
Twitter:@aviars

Mimi Saffer
Guest
Mimi Saffer

Richard – Thank you for bringing up registries, which don’t seem to be getting much attention in the ongoing national conversation about healthcare and information technology. This is unfortunate because registries are such an essential tool to improving care and outcomes. I cannot answer your questions about today’s EMRs and registry/population care support. But I’d like to make two points: first, “external” registries (independent of EMRs) are here to stay, and second, EMRs and external registries can interoperate and already are in at least some situations. To the first point: external registries are here to stay. EMRs should certainly provide… Read more »

C Brammer
Guest
C Brammer

Hello Richard – Good question, and one that many of us are challenged by -as you know. I’m not an HIT expert but, like you, spend a good bit of time on data aggregation for improvement. If i might, let me briefly try to clarify the problem from my perspective, and then i’ll pitch in two cents about whether and when things might change. THE PROBLEM Generally speaking, EMRs should do three things: 1) keep records and facilitate communication of those records among relevant providers; 2) pay bills and related admin functions; and, 3) have registry functionality (aka relational database).… Read more »