I spent a couple of days last week (June 10-11) at a conference co-sponsored by the HRSA Center for Quality and the NIH National Center on Minority Health and Health Disparities at which twenty of the highest-performing community health centers from the HRSA’s long-running Health Disparities Collaboratives (HDCs) described their accomplishments in improving primary care. They were stunning.
These health centers were not fresh-faced newcomers to the improvement collaborative du jour, but rather grizzled veterans who joined the HDCs ten years ago, have stuck with the method, and by now have embedded quality improvement deeply into their day-to-day operations and organizational culture.
If ever there could be a vivid demonstration of what is possible and right in the future of American primary care, this was it. Consider:
- At CareSouth in South Carolina, under the leadership of Ann Lewis, the annual average cost of care for a diabetes patient is $343, compared with $1591 at comparable community providers in SC. Outcomes for these 3500 diabetes patients have improved steadily, with 50% of HbA1c’s less than 7.0. Appointments are available within 2 days. Staff turnover at CareSouth is 3%.
- At FamilyCare in West Virginia, CEO Martha Carter has overseen a steady, radical improvement in diabetes care. Since 2002, the diabetes panel has increased from 1000 to 2700 while at the same time their average HbA1c has dropped from 7.8% to 7.1%. In the same period, the percent of pediatric patients with ER visits in the previous 6 months declined from 70% to 6%.
As team after team presented their stories, it became clear that these results were being achieved by safety net organizations on shoestring budgets, with highest-risk populations, despite the extra burdens of improvement work, data management and reporting. At La Clinica de la Raza in Oakland California, since 2007 100% of persistent asthmatics have been on controller medications. At Holyoke Health Center in Massachusetts the percent of diabetic patients with HbA1c’s over 10 has declined from 29% to 10% since 2000. At Hunts Point-Mott Haven in New York City, asthma hospitalization rates have decreased by 58% since 1997.
Together, these CHC leaders described a radically transformed model of primary care based on a fundamental change in attitude: instead of caring for patients ‘one at a time,’ they have accepted responsibility for a population of patients, based their criteria for quality on measures of the whole population, and persistently sought ways to improve those measures.
All of these high-performing health centers relied on information technology to achieve and measure results. But they referred to their systems as ‘registries’ – not as ‘electronic health records’ or ‘EMRs’.
EHRs versus Registries? – Lets Talk About Functions Instead
Despite the ever-present risk of oversimplifying a complex issue, and without worrying too much about what is really an EHR or a registry, let’s try to sidestep the controversy and focus instead on the software functionality that is needed to support the new model of primary care, as illustrated by these high-performing community health centers.
Today’s discussions of EHRs typically center on a relatively narrow range of functions that support the ‘one-at-a-time’ model of care: storing and displaying patient-specific clinical information at the point of care, reminding providers of the care needed by a patient during a visit, increasing the reliability and safety of common processes such as ordering tests and prescribing medications. When patient data can be readily shared among providers, these benefits are amplified across the continuum of care. These functions are important, but are only part what is needed to improve quality.
The registry functions described by high performing CHCs focus on using data to directly monitor and improve care for a population. We can distinguish two broad levels of registry functionality.
‘Base level’ registry functions are the starting point for practices working on quality improvement and are widely familiar to those participating in improvement collaboratives. They include:
- Planning care for individual patients in advance of an office visit, based on evidence-based protocols
- Providing ‘opportunistic’ care – that is, take every opportunity to provide care, even if it is not the reason for the visit
- Tracking quality indicators (for example, the percentage of diabetic patients with current eye exams) to evaluate effectiveness of process improvements
- Identifying gaps in performance to prioritize process improvements
The high performing CHCs who presented at the HRSA/NIH conference, many with over 10 years of experience in sustained care improvement, described uses of their registries that extend far beyond either EHRs or base-level registry functions. Advanced registry functions mentioned by these teams include the ability to
- Stratify patients by severity in order to target planned care (for example, patients with DM with a recent increase/decrease in BMI)
- Provide patient-specific outreach reminders to patients for needed care
- Create individual patient care plans with goals, track patient progress against the plan, and identify subgroups of patients based plan progress
- Identify subpopulations (by gender, age, geographic area) to differentiate process improvement interventions
- Identify subpopulations with special needs to launch community-wide campaigns (e.g. high utilizers with no insurance and special needs)
- Provide ubiquitous performance feedback to motivate providers and staff
- Identify groups of ‘non-compliant’ patients to diagnose causes and target interventions such as promotora, case management, or group visits
- Organize, coordinate and schedule ancillary and community-based services
- Create and manage provider panels
- Deliver transparent provider-specific feedback to encourage productive competition
- Identify patients for clinical trials
- Distribute a newsletter to all families in the practice that includes current performance data
- Summarize utilization improvement and cost savings for negotiations with payers and networks, and to obtain grant funding
HITEP or Mis-Step?
As I listened to the conference presentations, I scribbled notes. I was pushing a deadline to respond to a Request For Comments from the Office of the National Coordinator for Health Information Technology (ONC) [http://edocket.access.gpo.gov/2009/pdf/E9-12419.pdf ] regarding a proposed ‘Health Information Technology Extension Program’ (HITEP). This program, fueled by $2B of stimulus funds, envisions a national network of ‘Health Information Technology Regional Extension Centers’ which will employ ‘extension agents’ to coach providers on the selection, implementation and ‘meaningful use’ [whatever that means] of certified EHRs.
Parsing the RFC during coffee breaks, I was struck by the disconnect between the ‘silver bullet’ overtones of the ONC’s vision of EHRs everywhere, and the dogged improvement work being carried out by the CHCs presenting their results to the audience of HHS personnel and health services researchers.
I was also struck by the fact that no ONC staff attended the meeting, although many agencies across HHS were represented. So I fear that the message about the software functions that are so ‘meaningful’ for quality improvement will go unheard as HITEP is put into play.
As I was leaving the conference I talked to a physician leader of one of the CHCs who was in charge of his center’s EHR adoption project. His center has been a long-standing user of registry software and has accomplished dramatic improvements in care. Their group adopted an EHR product based primarily on it customizability, and he has personally spent half of his time for the past two years reshaping the EHR software to support the registry functions that his practice has come to rely on.
More than ever, I am fearful that the ONC is pushing technology for technology’s sake, without thinking through the software functions that are actually needed by the providers who are pioneering the transformation of primary care.
ehrRichard 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.