Quite
a number of threads are coming together this winter as meaningful use meets
HIEs meets ACOs meets patient engagement meets provider engagement meets… A lot
of meeting going on, but not much in the way of effective outcomes including
clinical outcomes. Several reviews of HIE & ACO effectiveness have recently
presented statistics, or at least a series of numbers, appearing to show that
HIEs have not captured either payers or providers approval as a way of sharing
healthcare information that is productive & cost-effective, & that ACOs
have, for the most part, not delivered on the model of shared savings & so
have proved riskier than initially hoped. Of course, the jury is still out on both
of these models, but the initial results are not highly positive.[1]
HIEs are having a hard time, especially the
public HIEs originally funded with HITECH money. The cited report states that “95% of payers, 83% of hospitals and 70% of
physicians said HIEs funded by federal grants have flawed business models and
do not assist with meaningful connectivity (Goedert, Health Data
Management, 1/27)”. “In
addition, 94% of surveyed payers said they did not see any "value
proposition" in public HIEs (Sullivan, Government Health IT, 1/27)”.
Coincidentally, the value of
EHRs is also being questioned. A recent survey by the MPI Group & Medical
Economics found that 45% of physicians believe that healthcare is worse as a
result of EHR adoption & 43% believe that EHR systems have resulted in
significant financial losses. In fact, 79% of doctors in practices with more
than 10 physicians said that their EHR investment was not worth the effort,
resources or the cost[2].
ACOs fare no better. Less than
half of the 114 ACOs surveyed in 2013 reduced per patient spending at all &
only 25% (29/114) broke even or reduced spending. In the Pioneer ACO program, 9
of 32 organizations exited the program after the first year & only 9 of the
remaining 23 (39%) reduced spending enough to receive shared savings. In both
cases, this is far below HHS’ or other policy makers’ expectation.
So why did I include engagement
in my introduction? I believe that engagement, both provider & patient, is
key to developing & maintaining sustainable operational & business
models for both HIEs & ACOs. I’ll address HIEs in this post & ACOs in a
subsequent one.
A recent IDC Health Insights
report[3] makes the controversial
statement that current EHR technology & by implication Stage 1 & 2
meaningful use have failed. By this they mean that even if you qualify for
meaningful use, you will not have the tools available to actually improve
clinical outcomes, improve population health & reduce costs[4] - & I can’t disagree.
To do so, you would need real capability for at least: provider-to-provider
connectivity, provider-to-patient connectivity, & clinical/ operational
functions such as care transition & medication reconciliation. Most EHR
vendors would claim to provide all of this, but the experience of providers
& their staff in actual healthcare organizations would indicate that the
capabilities that are provided are often incomplete, inadequate or just don’t
work very well[5].
So back to engagement… The fact
remains that providers are laser-focused on patient outcomes, & not
surprisingly, so are patients. If providers felt that EHRs, & other health
information technology used during patient encounters, were helping to improve
outcomes, they would be 100% in favor of them. The same is true of HIEs. The
fact that they are not highly supported by providers only means that their
design & implementation, including the workflow changes needed to utilize
them productively, has not yet been directed at what providers & healthcare
organizations (including payers) need of them.
I have previously written
(& will write again) about the importance, indeed the necessity, of
integrating new technology into clinical & administrative workflows so that
providers & the staff of healthcare organizations are comfortable with
using the technology. This is true whether it is a practice management system,
an EHR, a public health reporting system, ePrescribing, CPOE, clinical decision
support or any other technology-enabled capability. It is doubly true for HIEs.
What is the appropriate integration point, technically & operationally, to
introduce information from external sources into a provider’s workflow? I don’t
know if there is a “right” answer, in fact I suspect that there are several
workable answers, but it seems that HIE-level workflow integration of external
data should not be all that different from the integration of data from
internal sources (PM, EHR etc.). Other than identifying the source of the
information, it should be the same. This way there are not several different
“informational interruptions” as the provider works with the patient.
Here are some guidelines for
engaging providers in HIE:
- The technology must be well-aligned with the actual work being done (not some idealized or aspirational view of the work)
- The technology must provide capabilities that allow providers (& other users) to perform their work more efficiently &/or effectively
- The technology must be simpler to use than the current means of accomplishing the work
- If it is not simpler, it must provide substantially more of the capabilities needed to accomplish the work such as:
- Provider-to-provider connectivity: eReferral, Direct messaging
- Patient-to-provider capability: email, SMS or other (secure) messaging, social media interaction
- Care continuity & transition tools
- Medication reconciliation tools
- Integration with public health & emergency services systems
- Others as shown to be necessary
- Information must be pre-loaded so that it is available for access when the provider is with the patient
- Information should be presented when the provider accesses similar local data (medication history, encounter history, etc.) or on demand by user, but not at other times
- Information source should be presented so that the user can have an idea of data credibility
- Alerts should be kept to a minimum (or level should be adjustable) so that “alert fatigue” can be avoided
This set of guidelines is:
informal, incomplete, experiential, but also may provide a way to engage the
provider in HIE usage. The data presented from external sources should be
smoothly integrated with the provider’s workflow so that it is presented as an
enhancement to local available data, not as a separate set of requests or in a
separate workflow. More data can lead to better diagnosis, treatment &
outcome which is a win for both provider & patient, & which can provide
more provider engagement (& patient satisfaction) & a better
sustainability environment for the HIE.
On the administrative side,
non-local demographic & patient financial data provided under the same
guidelines (except for capabilities) can improve the financial understanding of
the HIEs operations & lead to both cost reduction & greater efficiency.
Once HIEs are really
facilitating accomplishing the triple aim (better patient outcomes, improving
population health & per capita cost reduction), they will have reengaged
providers & be on their way to relevance & solving the sustainability
problem.
[1] http://www.healthdatamanagement.com/news/hie-survey-offers-sobering-results-on-value-47151-1.html, Health Data Management
accessed 30 January 2014.
http://www.modernhealthcare.com/article/20140130/NEWS/301309951/providers-net-uneven
results-from-aco-experiment?AllowView=VXQ0UnpwZTVDL2VlL1IzSkUvSHRlRU9vakV3ZEErTmM=#. Modern Healthcare.
Accessed 30 January 2014
[2] http://medicaleconomics.modernmedicine.com/medical-economics/news/physician-outcry-ehr-functionality-cost-will-shake-health-information-technol?page=0,0
[3] http://www.healthcareitnews.com/news/new-do-lists-loom-post-ehr-era?single-page=true. U.S. Healthcare Provider Predictions for 2014.
Accessed 3 Feb 2014.
[4] The triple aim, c.f.
D. Berwick et al. 2008. The Triple
Aim: Care, Health & Cost. Health Affairs. 27(3), 759-769 & many others…
[5] personal communication with many providers &
other healthcare professionals
