My Better EHR

Three hours into writing this week’s blog, I realized I had written myself into a deep hole. I was attempting to make the argument that if we are to evolve from existing EHR technology to a grand and glorious “EHR of the Future”, we must introduce some new and important requirements and capabilities. My problem is that the post had grown to over a thousand words, and I had yet to get to my main point. That is not going to work. So I am starting over. Here is my message, minus all of the background, explanation, pontification, and puffery.

We need a new and better Electronic Health Record.

It is tempting to call the EHR that I want for myself and for my family (you can use it too, if you want) the Lifetime Longitudinal Electronic Health and Wellness Plan and Record. Ok. So I can agree that this name does not yield to our habit of making everything in healthcare an acronym. LLEHWPR just doesn’t roll off the tongue. So, for simplicity sake, I am going to call it My Better EHR – and I will speak to the missing L, L, W and P. Those components are key!

What does My Better EHR do, or do better, than current EHRs - at least the ones I have used?

My Better EHR provides a perspective that is birth to death – call it lifetime and longitudinal. As a provider or a patient I may need to focus on a narrower time window to meet an immediate need but I want each and every episode of care and wellness planning session to be based on full knowledge and context of the past, present, and future.

My Better EHR is exceedingly granular. It contains every important health and wellness transaction, observation, value, event, and intervention. All notes, all labs, all images, all data. Taking this point to the logical and appropriate extreme, my Better EHR contains my DNA sequence. However, my family doctor won’t have to thumb through it to find out whether my elevated LFTs might be related to statin use. Store it all, show me what I need now and “blur” (don’t hide) the detail if that detail only confuses and confounds the immediate goal, whatever it might be.

My Better EHR is comprehensive. It can collect and, when necessary and appropriate, communicate, convey, and incorporate into health care and wellness planning the full context of my cultural, social, educational, environmental, philosophical, and spiritual background, choices, and preferences. That was a mouthful. Read it a couple of times – I had to.

My Better EHR fundamentally understands time, direction, velocity, and acceleration. Providers and patients alike need and want to know not only current status, but also the direction, magnitude, velocity, and acceleration of change – is XYZ getting better or worse and how rapidly? Change and acceleration are critical to effective health and healthcare decision-making.

My Better EHR provides role-based security and privacy features that give patients the ability to understand and implement policies to assure the right information is quickly accessible at the right time, to the right users. My Better EHR manages viewing and modifying information in a way that addresses the complex intersection of roles and responsibilities with care needs, circumstances and patient-choice.

Core to the use and utility of My Better EHR is that it addresses not just health, but also wellness. Health is, for better or worse, incontrovertibly tied to our concepts of injury and disease. Wellness addresses a richer, more personal, and more diverse concept. The constellation of life choices and pursuits that constitute an individual sense of wellness significantly extends the My Better EHR dataset. We must measure, monitor, and plan to this expanded view of what it means to the individual to be healthy and well.

Finally, and most importantly My Better EHR is about planning. My Better EHR is certainly an accessible ledger or chronicle of what was and is, as vetted by the patient and providers. But more importantly it facilitates and encourages the development and implementation of a plan to achieve each person’s self-described ideal state. My Better EHR allows all stakeholders to participate in taking inventory of resources, developing an explicit, realistic, aggressive set of goals, and acting as the “playbook” - communicating and coordinating all efforts to achieve the individual’s goals.

The concept of My Better EHR as a vehicle for improving health and wellness is founded on two key beliefs. The first is that every individual, to the extent possible, seeks to make and implement decisions that Promote Wellness, Maintain Health, and Restore health and wellness when the first two strategies fail. We all want to feel good about our life and our life-choices and we all need help implementing our plans. The second foundational belief is that EHRs that are carefully and capably crafted can promote rapid achievement of health and wellness goals and optimize individual and population health.

Understand, this description of My Better EHR is not simply a thought experiment. Rather, it is a roadmap for growing and expanding ChartPath, Our Better EHR.

Health Data Infrastructure Facilitated by Meaningful Use Standards

In my last blog post, I described the virtues of Meaningful Use. The short version is that Meaningful Use established economic incentives that drove adoption of Electronic Health Records and made the creation of a lingua franca of health discussions both necessary and possible. The three foundational components that were initiated or advanced by Meaningful Use incentives are the following:

  1. Vocabulary Standards
  2. Document Content Standards
  3. Data Transport Standards

While it would be possible to endlessly debate how completely and how well these have been addressed, I refuse to back down from the premise that rapid advances in these areas have established an infrastructure that allows us to push into new and more substantive and rewarding use of individual and population health data.

Several additional components of an information collection and distribution infrastructure have sprung up based on the ones described above. Important ones that I want to talk about are Personal Health Records, Health Information Exchanges, electronic prescribing (eRx) networks, and Data Registries. For now I am simply going to describe what they are. I will later probe further into their strengths and weaknesses.

Personal Health Records
My view of Personal Health Records is that a PHR is an EHR from a patient’s perspective. Think of it as the shoebox, manilla folder, or file drawer where we collect our current paper records. Imagine that all important records, receipts, pictures, videos, and other files relating to your care were stored in one place. Assuming they have been catalogued, tagged, and organized appropriately, this collection of information would be invaluable to anyone attempting to optimize your health. That is what I want and expect of a PHR platform. Patient-centric. Comprehensive. Accessible.

Health Information Exchanges
Key to providing access to the PHR information described above is a network of networks which can handle the health information exchange transactions in a way that assures delivery, manages authorization and notice, protects privacy, and does so efficiently and reliably. That is the essence of health information exchange.

eRx networks
Electronic prescribing networks are perhaps the best example of how important health data can be managed in a distributed but secure fashion. The rate of penetration of electronic prescribing has been phenomenal. I believe the reason to be the huge amount of money that prescribing represents, and also the importance of prescribing to our approach to health care. Leveraging a deep, rich vocabulary (RxNorm) and based on a combined commercial / public network infrastructure, we now have an exceptionally rich data set regarding the use of pharmaceuticals to treat patients.

Data Registries
Similar in many ways to the eRx network, rich repositories of data relating to a wide range of populations of patients have been established in Registries. These registries have begun to capture and organize information relating to patients who share some common demographic and/or health and disease attributes. A group to be studied is selected, then data collected about that population. These registries support the search for more effective therapy or successful strategies for reducing or eliminating the burden of a disease or health risk. I view registries as “case reports” of what will become a broad strategy of health and wellness optimization based on Precision Medicine - an extensive understanding of individual characteristics that will allow us to tailor disease prevention and treatment to the individual.

Taken as a collective, these technologies and capabilities have pushed the use and utility of health information to the brink of broad impact on Triple Aim goals - better care, a better care experience, and lower cost. But there are key pieces of information infrastructure still missing. Check in next week as I share my thoughts on where we must go next if health information technology is to live up to its promise of promoting better individual and population health.

featured photo from healthaffairs.org

Introducing Dr. Memory to Meaningful Use

I have been involved in technology supporting effective healthcare for more than 30 years.

While working in emergency medicine back in 1986, I drew a mockup of an emergency department patient tracking system on a large sheet of graph paper with colored pencils. DrMemory19861-300x235.jpgThe information model was based on early spreadsheet applications and after first drawing it on paper, I mocked it up with a program for fleshing out computer graphical design. As you can see on the image to the right, we called it Dr. Memory, and it is dated September 1986.

By the way, I find it curious that Dan Bricklin was largely responsible for bringing the concept of the spreadsheet to computing and also was the key developer of the mockup program that I used to flesh out the design - I think it was called Dan Bricklin’s Demo. If you don’t know about Dan Bricklin, you should.

The problem I was trying to solve in the '80s was that in a large, busy emergency department with patients arriving and departing at a frenetic pace, it was very difficult to simply know where patients were and what the next steps were in their care. Care was provided by as many as 50 caregivers, and patients moved quickly through the process - at least we worked to make it so. Whiteboards were the most common method of tracking patients, and some hospitals even trained a camera on the whiteboard and broadcasted that signal to various locations around the department. Beyond the issues of simply managing a complex operation as the medical director of this department, I faced the Herculean task of extracting operational data from a handwritten log book that recorded a summary of patients, treatments, diagnoses and dispositions. Simple reports took hours of effort to extract data and do summary reports.

Our idea for improving patient tracking began as a colorful grid with rows of information about patients, became a multi-user application for recording care activity and timestamping the events. By capturing the events in real time, information could be shared among the providers and we could deliver better and more timely care. We knew how much easier it would be to collect more complete and reliable data for reporting. It was a simple idea, with really profound implications. What began as simply a patient tracking system evolved over several years to a full-fledged electronic health record. The range of activities that we tracked expanded beyond the operational into the clinical realm. That is where we encountered the greatest challenge to efficient and effective electronic health records - the issue of standards.

Standardization of data sharing, HITECH and Meaningful Use
For more than a decade, we struggled with issues of how to codify information to make it useful to users of other systems. How should clinical facts or findings be recorded in such a way that the information could be made sensible, understandable and useable after transferring the information to other systems? There were a few standards that were available. We had ICD-9 for diagnoses, but a system meant for classifying causes of death fell short of our need for clinically useful standards. HL-7 was an evolving standard of information exchange and worked well for some administrative functions, clinical orders, and a growing set of data from laboratory. LOINC began to deliver some added value through standardization of results. Mimicking many information systems, the best data was usually about the demographics and billing data. At least ADT transactions (Admission, Discharge, Transfer) were standardized and provided a model for data sharing.

Despite the availability of these few coding systems, the majority of clinical data was simply not mobile in a meaningful way. It was only with the arrival of HITECH and Meaningful Use that standards development reached what I consider to be a tipping point. Up to that time, most vendors could share data among users of their system - moving data across applications was difficult or impossible. Requirements for standardized data capture and movement pushed standards development in three key areas:

  1. Vocabulary standards: Clinical terms were defined based on standard vocabularies, providing reasonable commonality and the beginning of some “dictionaries” of clinical terms.
  2. Document content standards: In order to share information about important care processes it became necessary to define collections of data for common clinical scenarios - think of discharge summaries, operative reports, consultant reports, office visits, etc.
  3. Health Information Exchange infrastructure: Safe, secure, reliable transport of medical information over communication networks is critical.

There was no “magic” in Meaningful Use. There was no silver bullet that solved the myriad problems of health information exchange. But, what Meaningful Use did was incentivize enough providers and provider organizations to simply push forward and begin the iterative process of creating and then improving the sharing of health information.

I find it useful to compare health information exchange with an imagined challenge of communicating with an extraterrestrial society. We have a crude and rudimentary vocabulary, and we are able to tell some very simple stories and exchange this information over some distance. I would say we are at the “bedtime story” stage of communication, with a profound need to be able to discuss, deliberate, document, and commit to diplomatic level discussions.

We have a long way to go.

MACRA and MIPS are Coming - Are You Ready?

MACRA and the changes anticipated in provider reimbursement have risen to the top of mind for many of us working in PALTC (post-acute and long-term care). This is actually true across a broad spectrum of health information markets, as the impact is both broad and deep. Let me briefly explore some of the reasons I think this is true.

First is the breadth and size of the impact. Virtually every provider that serves Medicare patients is impacted by the new reimbursement methodology. As the program matures there could be as much as a 20% difference in Medicare reimbursement rate between the high-achievers and the low. In PALTC where the bulk of care is covered by Medicare, that difference is profound.

Second is the degree to which practices will be impacted. Providers must begin to demonstrate behaviors that positively impact the cost of care, the quality of service, efforts to improve their practice in a regular and systematic fashion, and implement health technology to serve these “Triple Aim” goals. Those are the requirement of the MIPS (Merit-Based Incentive Payment System) option under MACRA. The other path, which is not likely to be practical in the early years of MACRA for most practitioners is to generate a major portion of one's Medicare revenues via an Alternative Payment Model.

Third, this is happening fast. Current requirements will have measurement begin in 2017 (yes, the entire year and not just 90 days of reporting) with incentives and penalties being imposed in 2019. For several years the impact of the potential payment adjustments, both positive and negative, will grow. As stated above, there are large amounts of money “at risk”.

Fourth, the impact of MACRA extends well-beyond providers. This week saw a number of articles examining the impact that the new regulations may have on Patient Engagement. Efforts to bring a higher level of participation and patient engagement are perceived to be less well supported in MACRA and this has a lot of patient advocates concerned.

I am happy that many people and health care periodicals have written on MACRA and its impact. While no one has a clear crystal ball view of the ultimate outcome, and many fear the worst, only time will tell the net result of this massive overhaul of reimbursement methodologies and the health technology that supports (and hopefully promotes) effective post-acute and long term care.

Hold on to your hat!

Workflow challenge for post-acute & long term care clinicians

My commitment to curate and push substantive and meaningful articles relating to PALTC to anyone interested in this health care market is underway. I enjoy the part of the work that involves scanning my lists of source materials looking for candidate posts, but the challenge really begins when I try to assimilate the information, pick the most compelling or interesting articles, and generate a final product - call it the "workflow." I find this interesting because that is exactly the problem that we at Afoundria are working hard to solve for our PALTC charting customers - workflow.

ChartPath was designed and built to make it easier for doctors and nurses providing care to patients in a wide variety of settings outside of acute care facilities to create quality records of their patients’ care. (See previous blog post on The 5 C’s of Charting). Most of the thousands of charts produced by ChartPath customers each week are generated in what I term “facility-based” post acute care. This includes nursing homes (skilled and long-term) as well as assisted living and independent living facilities. Few of these facilities provide software that meets the needs of the providers ChartPath serves, rather their focus is on their own documentation.

Thus, the workflow problem. The source information for a high-quality chart comes from many disparate systems and processes. Documents of prior care including discharge summaries and progress notes may be available in electronic or paper form. Current and previous medication administration records (MAR) must be reviewed and vetted. Notes of care generated by facility staff should be reviewed and compiled. Other individuals on the care team including therapists, specialist consultants, dietary and nutrition staff, nurses and nurse aides can provide valuable input into care planning and coordination. Oh, and lest we forget, the patients themselves are both a vital source of information and the target of care.

Reviewing, vetting, curating and publishing a patient chart is much more complex than my challenge of pushing out news articles of interest - not to mention our users create hundreds of charts per week. But my efforts to collect, assess, assimilate and publish succinct and informative summaries of important information directly parallel their challenge and remind me of our purpose. My pledge to you is that each week as I work on this editorial post I will find something in our ChartPath product, big or small, that needs to be “tweaked” to make our customers’ work easier and more satisfying.

To our customers, the providers of PALTC - thank you for all you do.

Dr. Buddy Owen