David W. Bates, MD, MSC is the Chief Quality Officer, and Chief, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA.
The Medical Home is one of the most exciting developments in care redesign in some time. Although the concept was initially developed many years ago in pediatrics, it is just now being widely implemented, and it has great potential to change the way care is delivered, in particular by devoting additional attention to the sick who consume a high proportion of resources, and by broadening care delivery, so that an entire team is engaged with the patient, rather than just the individual physician. All of this is much easier to implement because of payment reform initiatives which are being implemented, including accountable care organizations, bundling, and shared savings programs.
At the same time, providers across the U.S. are rapidly adopting electronic health records. But how well do the EHRs of today support the care that needs to be delivered? In a piece published last year in Health Affairs, Asaf Bitton and I argued that there were seven domains which will be especially important going forward1: clinical decision support, registries, team care, personal health records, care transitions, telehealth, and measurement. In this blog, I’ll go over how I think today’s vendors are doing with each of these.
Clinical Decision Support
Clinical decision support can make a big difference now, especially for preventive measures and some of the key chronic diseases which are well-delineated, including diabetes and coronary artery disease. But most of the records on the market today include little if any decision support. A few of them do, and many more will allow the enterprising provider to program their own rules. But that takes a lot of time and effort and is just not practical for most providers today. For other chronic diseases like congestive heart failure and asthma, we are still working out what decision support will make a difference.
These will be fundamentally important as we try to improve care for specific populations. Here, I’m focusing mostly on registry tools that can be used inside the practice to make sure that populations like diabetics get key care items addressed. The ability to export data to outside registries such as those run by a specialty society is also useful but is secondary. However, most EHRs include little if any functionality— often you need to export your data to another application (which is not a bad approach). The kind of tools that providers will want include tools that: 1) let them rapidly identify the sickest patients within a group or indeed across diagnoses; 2) allow them or another team member to send a letter, generate an email or order a lab test; 3) that make it much more efficient for the team to carry out many of the key processes central to coordination of care. Such tools largely don’t exist and will be needed to manage care more effectively.
One of the very most important parts of delivering care in a medical home as opposed to the way things are done in a standard practice is that care is distributed among members of a team. This means that the EHR should support communication and delivery of messages within a record, and also to those at the margins such as specialists who are working with the practices. Often there is a need to discuss something about a patient in ways that do not become part of a patient’s notes. Such tools today are largely non-existent.
Personal health records
Personal health records — likely tethered to the EHR — are likely to play a major role in helping patients become more empowered, so-called self-efficacy. They can enable the shifting of care from visit-based to virtual. This is effective even with fairly limited personal health records, which are widely available from many of the main EHR vendors, so the situation is less gloomy than for many of the previously mentioned domains.
Care transitions represent an extremely vulnerable time, and for obvious reasons transitions have become a major focus. A number of tools within the record can help with transitions, and prevent readmissions, with medication reconciliation tools being perhaps first on the drawing board. However, few EHRs have sophisticated tools to enable reconciliation, though some have been built.2 At a lower level, it is essential for practices to know when their patients are discharged and to set up approaches to get them in rapidly.
The role of telehealth is still unclear, despite the many studies that have been done in this area. But it seems clear that it will be beneficial for at least some populations of patients, and that telehealth approaches will need to link with EHRs and let providers know when something important or actionable has come in. Nonetheless, little of this is taking place today, though most records can consume HL-7 messages, or even CCDs.
Most quality measurement will be done in the future using the EHR, as routine care is delivered. As part of meaningful use, an increasing number of measures are being specified, and this domain lends itself to specification more than many of the others. Still, the dream of having all ones measurement take place without the provider needing to make a lot of extra effort is quite a ways from being realized.
Overall, this assessment makes it clear that there is a lot of work to do. But the vendors should not necessarily be taken to task — they deliver what providers ask for, and until recently providers have not focused on care of populations or improving efficiency. As payment reform changes the incentives for providers, though, we are going to need all the above tools and functionalities and more — and I predict that the practices that do the best will be ones that find ways to leverage them. Even today, it is essentially not possible to set up a medical home without using an EHR, but the EHRs of today will seem old-fashioned in a few years.
1. Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood). Apr 2010;29(4):614-621.
2. Schnipper JL, Liang CL, Hamann C, et al. Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge. J Am Med Inform Assoc. May 1 2011;18(3):309-313.
Disclaimer: The views expressed are the opinion of the author and do not necessarily reflect the policies or views of the organization with which he is affiliated.