Population Health or Bust!

My April editorial post for Clinical Innovation + Technology is called "Population Health or Bust!".   The premise is that we know reimbursement models are changing from "Volume-Based to "Value-Based care", which may range from gain-sharing to bundled payments to full capitation... And thus we need certain types of tools to better manage our populations of patients.  So I defined what these population management tools should do and what to consider when purchasing them:

First, population health management means that you (1) define a specific population and (2) manage that population in the most efficient, cost-effective and highest quality manner possible.  In other words, instead of treating everyone the same, you provide the right care to the right people in the right time and in the right format. This helps to ensure that we focus our limited resources on the people who need them most, while using innovative strategies and technologies to leverage care for others.

Second, be on the lookout for some key functionalities when choosing your population management tools. These include risk stratification, impactability analysis, care gap identification, outreach capabilities, care coordination dashboard, patient engagement systems and analytics reporting.

Third, population health tools are everywhere right now, including offerings from your EHR vendor, your insurance companies and various third parties. Factors to help guide your decision will include not just the strength of their offering, but their ability to integrate into your workflow, their ability to work with multiple data sources, and their future visions. Additionally, we are starting to see interesting gain-sharing business models that may make initial investments free or cheap.

I ended my post explaining why I believe that when dividing populations into "Low, Medium, and High" risk, that the really cool innovations (e.g. mobile monitoring, telehealth, automated care) will be in the Low and Medium categories, rather than the High risk ones.  And furthermore, that this will hopefully open up more free time for physicians to spend with the "High risk" patients who needs more of the face to face care we consider traditional right now.  Said another way... let's automate the easier stuff so we can allow for more time, critical thinking and compassion for the tougher stuff! 

Companies in the Population Health Space (at least a partial list)

·         Advisory Board Company:  www.Advisory.com

·         CareMerge (focus on elderly):  www.caremerge.com

·         Care Team Connect:  www.careteamconnect.com

·         Clairvia http:  www.clairvia.com

·         Click4Care:  www.click4care.com

·         Clinigence:  www.clinigence.com

·         Curaspan (SAAS – Handoffs):  http://connect.curaspan.com

·         Essence HC:  www.eghc.com

·         EvolentHealth (UPMC + ABC):  www.evolenthealth.com

·         GSI Health (Lori Evans) (CC Platform):  www.gsihealth.com

·         Healarium (Mobile Pt Activation Apps):  www.healarium.com

·         Humedica (bought by Optum 1/13):  www.humedica.com

·         Intelligent Healthcare:  www.intelhc.com

·         Lumeris (ACO for hospitals):  www.lumeris.com

·         Medventive (bought by HBOC 2012):  www.medventive.com

·         Outcome Advantage:   www.outcomeadvantage.com

·         Patient Point:  http://patientpoint.com/

·         Pharos (Dz mgt, Randy Williams):  www.Pharosinnovations.com

·         Phytel:  www.phytel.com

·         RipRoad:  http://riproad.com/

·         See Change (Insurance and Systems for Employers): www.seechangehealth.com

·         Symphony (ACO Software):  www.symphonycaresolutions.com

·         TCS:  www.tcshealthcare.com

·         US Health Centric (Dx/Wellness mgt):  www.ushealthcenterinc.com

·         Valence Health:  www.valencehealth.com

·         Vital Health:  www.vitalhealthsoftware.com

·         Wellbe.me (Checklist based Workflows for Discharges):  wellbe.me

·         Wellcentive:  www.wellcentive.com

·         xG Health Solutions (Geisinger Spin-off):  http://xghealth.com/ 

I will edit this list over time - but it gives one a sense of how many companies are already in the space in one form or another (and this does not even include all the EMR vendors and their offerings).

The Real EMR Incentive: We want LONG-TERM EFFICIENCY, not short-term funding!!!

This is a mantra I have long been espousing, and it was nice to see a recent report from the CapSite research firm backing up this assertion.  More specifically, this study of more than 2000 medical groups across the US found that "the most important reason driving Ambulatory EHR purchases was the goal of physicians making their practice more efficient and not the ARRA / HITECH Act Stimulus funding".

Said another way, to get real adoption - we need to figure out how to promote USABILITY not just Certification.  And let's continue to move from the inefficient paper-based paradigm (EMR 1.0) to the much more appropriate web-based or iPhone paradigm (EMR 2.0).   My last post, which talked about "The Future of EMRs", provides more details on this idea.  And I am looking forward to learning more on this topic when I go to SanFran this week for the "Annual Meeting of the Human Factors and Ergonomics Society" - where I will be listening to the top experts across all fields, as well as speak on a panel of EMR aficionados discussing the importance of improving usability of these tools.

So what can we (especially the government) do if this concept is true (the key to adoption is Efficiency)?  Maybe we should reconsider how we spend the $30+ billion in HITECH funds?   Perhaps instead of giving "relatively" small grants to a lot of doctors, we use the money to help the whole industry create more Efficient and Usable products?   Myself, and others, have brought up this concept before (see "How should we use $36 billion to promote EMRs").   But it becomes more relevant when one of their own ask the question, which just happened:

As reported in this article, at a recent DC conference, former Secretary of the Treasury Paul O'Neill (who has authored academic papers on patient safety with current Medicare chief Dr. Donald Berwick and Lucian Leape) posed a technical question to keynote speaker Dr. David Blumenthal, the National Coordinator for Health Information Technology: "Why is it that we're reluctant to declare that we are going to design the best prototype that we can with an idea that we will have [iterative versions] as we learn more and we identify more needs?  Why is it that we can't call to question and get on with what's a clear and apparent need for a national standard that's a work in progress?  It's not that it has to be perfect from day one, but your office basically says, 'We're going to do this now?'," O'Neill said before a packed house of doctors and administrators of corporatized health systems. 

Dr. Blumenthal's answer did not clear things up as he talked about analogies to the interstate highway and the Internet - which actually seemed to hurt his own conclusion.  In other words, if you look at those government investments - you see that they created the infrastructure upon which others could build.  They did not involve the government giving money to end-users (e.g. local truckers) to buy and install concrete paths themselves, nor did the government give money to Internet end-users to buy and install web-servers themselves.  And yet, here we are - giving money to end-users (physicians) to buy and install a variety of proprietary systems that don't talk to one another without heavy lifting since each vendor creates their own versions of the concrete road - with proprietary data models and back-end functionality.

If the government believes in these past analogies - then they need to reconsider how they distribute their EMR monies...perhaps building a single standardized EMR platform (like they do with highways or Internet protocols) upon which the vendors can add their "value" and healthcare providers and patients can benefit from consistency and competition around the key issue at hand - Efficiency.

DrLyle's Take on the Meaningful Use Rules

I wrote up some notes about MU last week and the folks at HISTalk published it - here is the link to that posting (as well as some interesting comments from others):
DrLyle's Take on the Meaningful Use Rules 7/30/10

And here is the text from that post, with links to resources on the bottom:

In mid-July, the government released the final rules on MU and EHR certification. I was actually at the perfect place for this — the annual meeting of AMDIS (Association of Medical Directors of Information Systems). So we had 200 CMIO-type docs and a panel of speakers ready to talk about this topic. HIT geek heaven!

From my bias of focusing on ambulatory EMRs, here is what I learned at this meeting from listening and talking to some very smart people on the topic and reflecting on everything the past few weeks:

Big picture stuff
MU Rules are reasonable. The government listened to the end users and decreased the expectations on the "Core Rules" (decreased the percentage of eRx required), while putting other rules in an optional "Menu" (i.e. choose five of 10). But be aware, anything optional you don’t do in Phase 1 will be required in Phase 2 in 2013 (i.e. you’ll need to do 10/10 from the Menu)… and they will likely think of more things to add by then.

MU Rules are still not a slam dunk. Even for mature users, there will be work that needs to be done. It is hard to believe that a non-mature user, or users without a lot of resources, will be able to easily accommodate everything.

The government seems to think this will really work well and we will see over 50% adoption by 2015. I would love that, but am less optimistic. Best quote I have heard is that MU incentives are like giving someone money to have a baby. You will have a baby if you want a baby. The money is a nice extra, but not the main driver. Change is hard, so I am hoping that while we keep asking vendors and users to add functionality, we consider how we can improve usability at the same time.

I do hope the government is at least working on a secret Plan B in case 2015 comes and we are only at a fraction of where we need to be (e.g. maybe they give money to innovation think tanks to figure out better EMR user interfaces). If you want to read more about the rationale behind having a Plan B, check out the great Kuraitis/Kibbe blog on this topic.

Per John Glaser, we need to think about MU not as a simple, one-time incentive, but rather as a stepping stone to bigger reimbursement reform. In other words, it helps groups create the HIT foundation for alternative care models and payment reform of the future (e.g. Medical Homes, ACOs). In that future, an EMR is no longer a competitive differentiator, but rather how we use our EMRs will be the differentiator (e.g. care efficiency and improvement, use of clinical decision support, secondary use of data, and patient engagement).

Some details that popped out at me
1. The denominator is now "unique patients" rather than patient visits. So if a patient is seen three times in a year, you just have to fulfill the rule at least once for that patient.
2. Scoring will be done on an individual physician basis, not on a group-wide analysis.
3. To correctly measure many of these details (e.g. give clinical summary to 50% of those who ask) we would need to figure out a way to keep track of who "asks". That seems like a strange request for structured data and certainly should not be what a doctor is spending his time doing. So either we need to make it an easy administrative chore or consider doing it for 100% of people automatically.
4. For patient reminders (for patients over 65), physicians can decide content and format. For example, we can decide to just do colonoscopy reminders and only do it via mailers to patients — it does not have to be electronic. The point is to just prove we can identify patients by age and communicate with them in some way.
5. Patient education. We need to figure out a way to document when we provide these handouts. Some EMR systems may have that built in, but even then, just for the handouts they have. What if I go online and print something else out? Or give them a special handout I have created? We may need to create a special patient education section to document this, but it is again more busy work for physicians (which I am not a fan of!).
6. EMR vendors are on the hook. They are required to ensure some level of MU reporting from their EMRs to get certification. The result will likely be that they will be spending a lot of extra time and money preparing their EMRs and then trying to get everyone to take those upgrades. They will then likely just certify the most recent version of their system.
7. EMR users need to upgrade, due to above point. It is unclear how all current EMR users are going to be able to quickly upgrade their systems in the coming 6-12 months. That takes a lot of planning, time, resources, and money. I wonder if users of "older versions" will band together to try and get their older versions certified, or if the vendor will help at all?

Resources
• The NEJM summary from Dr. Blumenthal
• A summary from Computer Science Corporation (CSC)
•  Full text of the MU rule from HISTalk
*  MU PPT Slides from CMS
* The HHS FAQ about MU

Our Healthcare System: Update

A variety of websites and stories which I found to be important or at least thought-provoking:

Key Web sites
• http://healthcareforamericanow.org/
-- The best site I have found to simply explain, "What does the new health reform law mean for YOU?"

• http://www.healthcare.gov/
-- The federal government's site that includes specific advice on how to find health insurance and how that is impacted by the new health reform law.


Healthcare IT stories
• Use of HIT Improves the Quality of Care
-- A Kaiser Permanente Study Finds Quality of Care Scores Increase as Patients and Physicians Communicate via Secure E-mail.

• Improving Usability of Health IT for Physicians
-- A great article in Healthcare Informatics which starts by pointing out that most health professionals do not use available health IT systems because they actually increase their work effort and can too frequently hurt quality, whereas the objective should be to help physicians decrease their work effort while increasing their quality consistently. They offer thoughts on a "physician-specific point-of-care system that continuously adapts to practice patterns that could result in dramatic improvements to the quality and efficiency of healthcare delivery".


General Healthcare Stories
• Process improvement to improve compliance with specialty visits
-- Turns out that when a PCP refers a patient to a specialist, they only make the appointment 70% of the time, and of those - only 70% show up - thus less than 50% of people go to the specialists when they are referred! This article talks about how a process improvement improved those metrics. Our medical group (www.NMPG.com) does something similar to help with this process and we believe it provides a higher quality and more efficient process for sure!

• Better ways to manage the flood of test results
-- New recommendations target how physicians and hospitals can best communicate test results and prevent harm to patients.

• Aftercare Tips for Patients Checking Out of the Hospital
-- NY Times article on how good discharge planning can keep patients from needing to be re-admitted after leaving a hospital, and could save Medicare billions.

• How the Performance of the U.S. Health Care System Compares Internationally (2010 Update)
-- Yet another report, placing the US healthcare system last among industrialized nations. US spends $7,300 per person per year on healthcare and gets the worst results. UK spends $3,000, New Zealand $2,500; Canada $3,900; Australia $3,400.

• Health overhaul may mean longer ER waits, crowding
-- Due to a shortage of primary care physicians (PCPs), Emergency Rooms may grow even more crowded with longer wait times under the nation's new health law since there will be many more patients with insurance, but no increase in PCPs.

• The Variability of Patient Care - by John Glaser
-- One of the smartest guys in healthcare explains the theory from one of my favorite books (Designing Care by Richard Bohmer),which I talked about in a previous post about Checklists and process improvement. The key point being that there are two classes of care in a hospital and in a physician's practice, and the importance of understanding that these two very diverse scenarios need to be recognized when designing process/workflows for care (especially including use of EHRs). Glaser explains further;
---- Sequential care is a form of production: It involves performing well-understood tasks in a well-understood sequence (e.g. routine heart surgery). Sequential care's mental image is that of a production line. With sequential care it is possible to engineer a preferred sequence of steps and have the EHR guide the care team in performing these steps. And it should be quite possible to measure the outcomes of these steps. (This is similar to Clay Christensen's Value Added Process)
---- Iterative care is a form of discovery: It addresses complex diagnoses and conditions for which the diagnosis and treatment are a repeating series of hypothesis-test/treat-revise hypothesis steps. Iterative care is different. The mental image should not be the factory floor but a group of scientists in the laboratory. In this scenario we must encourage collaboration, enable an unpredictable set of actions to be taken, and provide easy access to information and other experts that might help the team form and test hypotheses. Measuring the outcome of discovery is very difficult. (This is similar to Clay Christensen's Solution Shops)

The Dark Side of EHRs

Sir Cyril Chantler noted, "medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous." His quote was from a Lancet article in 1999 - much before EMRs were being used regularly. I wonder what he would say now!

I blogged back in February about the FDA's consideration of regulating EMRs... and a series of recent stories have come out reminding us of the unintended consequences of using information technology in healthcare… the truth being that problems occur due to a combination of issues, including;
• Implementation problems, such as forcing through awkward workflows.
• Technical problems, such as failed integration, slow speeds, system outages and true errors in the system design (e.g. 1 + 1 = 3).
• Usability problems, such as difficult to read screens, which can affect speed and judgment. Something I've been commenting on a lot in the past year, as in blogs of April, 2009 and August, 2009.

Here are two interesting stories from the Huffington Post Investigative Fund (a new nonpartisan nonprofit dedicated to in-depth reporting):
As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge : A device that is central in the shift toward electronic medical records systems has been linked to instances of death or injury, according to an Investigative Fund review of Food and Drug Administration data.

Amid Digital Records Surge, a Lack of Policing by the FDA: As federal officials encourage the rapid expansion of electronic medical records to help doctors improve care and cut costs, they lack a reliable and systematic method for tracking the safety of these products, agency data and audits show.

Finally, my friend Dale Sanders, a well-known healthcare CIO, wrote an excellent blog bringing the personal touch and common sense thoughts to this topic of Patient Safety and EHRs.
I love this quote: Remember when safety belts in automobiles first became popular? They were simple lap belts, no shoulder strap. Did they aid passenger safety? Yes, in some ways… but they also introduced the danger of a whole new range of injuries, such as lumbar separation and paralysis, which hadn’t previously existed. It wasn’t until we added shoulder straps and the three point anchor to seat belts in cars that the evidence of benefit to passenger safety became clear and without question. We need pause now and add shoulder straps to EHRs.

If you are interested in searching the FDA's database for HIT problems, or submit one of your own, you can do so at MAUDE (Manufacturer and User Facility Device Experience)

With all that said, this should not stop the forward march of EMRs and HIT from helping us improve the quality and efficiency of healthcare... but it should certainly remind us that we are FAR from our ultimate destination and we all (vendors and users) have to figure out how to build, implement and use these systems better and better...

Other stories and articles
NY Times article (April, 2010) on how EMRs in the exam room can provide so much info that it pushes a doctor into “cognitive overload”

The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry (JAMIA, 2007)

Overdependence on Technology: An Unintended Adverse Consequence of Computerized Provider Order Entry (AMIA Conference, 2007)

The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration (Intl J of Med Informatics, 2009)

Rush to Electronic Health Records Could Increase Liability Risk
(Insurance Journal, June, 2010) which references this paper:
E-Health Hazards: Provider Liability and Electronic Health Record Systems

Nov, 2011: EHRevent.org has been created in collaboration with medical professional insurance carriers and adverse event reporting and government experts to improve EHR and patient safety and help to reduce professional liability. EHR event reports will be provided to participating EHR vendors and kept confidential by PDR Secure™.  Information from the PDR Secure PSO may be used by medical professional insurance carriers and the FDA to better understand EHR events and to develop education materials that will increase patient safety and benefit physicians and other clinicians in their use of EHR technology.

“Good software includes superb usability”

HISTalk just published a fantastic interview with Ross Koppel, PhD, a sociologist who has researched and published on the problems with HIT systems – focusing mostly on errors with CPOE, but can be easily applied to ambulatory EHRs as well.

At the beginning of the interview, he says something that needs to be better understood in the marketplace: “Vendors seek market penetration ASAP because user implementation costs prevent reconsideration of other options once a hospital or even medical practice is committed. But vendor product cycles do not allow the ongoing feedback and adjustments that allow rapid improvements. The vendors are eager to roll out new iterations while the industry structure does not encourage patient safety or the actual needs of hospitals and clinicians.” In other words - be careful with your first choice... it's a very long relationship and you better know what you are getting into!

He further elucidates that non-disclosure agreements (and/or other company policies) mean that when the vendors get feedback about problems, they are neither sharing them amongst all users nor are they prioritizing them based on true clinical needs. Specifically he says that “…the vendor picks and chooses on the basis of a market model and a marketing strategy, not on the basis of what is greatest for the greatest number of patients and clinicians. Now, if that were transparent and we could see that there are, of the 1,500 complaints, there have been 10,000 dealing with — those are categories of complaints — I don’t know, the impossibility of entering allergies, or when you enter an allergy, it wipes out the previous allergy. So if the first allergy was anaphylactic shock and the second was a mild rash to latex, anaphylaxis dies, disappears, and you get the mild rash to latex coming up.” In other words, do your best to make sure your vendor shares all the feedback they receive, and that the current customers have a strong say in prioritizing what gets fixed.

And I love this quote near the end: “Now, why do clinicians accept this? It’s because they didn’t go to law school. And by the way, I’m speaking very soon to a group of healthcare lawyers and the like. The CMIOs come to me and say, “Look at this, we bought this and now we can’t address this,” and the lawyers for the hospitals say, “Schmuck. People come to me with a $5,000 contract to make sure it’s passing muster. You signed a $100-million contract, and now you come to me now that you’re stuck”. Enough said.

And when asked what he would change, Dr. Koppel wishes there was simply better software to do what we all want, and intones the universal chant we are hearing more and more… “Good software includes superb usability”.

Bottom line, this interview should be required reading material for all CIOs and CMIOs working with any HIT vendors!

Also check out: The HIMSS WhitePaper on EMR Usability

Improving EMRs: Usability, Usability, Usability

I've been working on physician adoption of EMRs my whole career, sticking to the mantra that "there are no benefits without use". And I've been fortunate in the past few months to be able to focus some extra time on this topic as part of a project on "The Future EMR" sponsored by the Szollosi Healthcare Innovation Program (http://www.theshiphome.org/).

I think this topic of Physician Adoption of EMRs is particularly relevent due to the recent Health Information Technology for Economic and Clinical Health Act (HITECH) bill for funding "meaningful use" of EMRs in an environment which has not yet seen much adoption, as evidenced by a Fall, 2008 NEJM article which found just 4% of US doctors using a "fully functional" EMR in the outpatient environment, and only 15% using a "basic one" (NEJM, July, 2008: Electronic Health Records in Ambulatory Care — A National Survey of Physicians).

So while adoption has many mothers, I'm going to suggest we are wise to focus on the "Three I's" to understand how to improve adoption:

(1) Interoperability: What a bugaboo. While many say that we don't have enough, I'd actually argue that we are so obsessed with this issue that we are losing the forest for the trees. In other words, let's get doctors using systems first, and worry about interoperability later. I realize that is a bit heretical, but the truth is that the majority of healthcare is local - and what we really care about is making sure that our EMR interfaces with our local PM system, lab, Xray facility, etc... rather than worrying about some regional or national sharing. The latter is still important, and there are always great anectdotes about having access to an ECG when on vacation, but let's start shifting some of the interoperability obsession to usability obsession (which I understand CCHIT is doing - and I approve!). Meanwhile - tell your patients (at least the sick ones) to keep a piece of paper in their wallet with: allergies, meds, problems, the names of their doctors and perhaps a copy of their ECG. I guarantee that one of the first thing paramedics do is go through someone's wallet or purse to look for this type of info.

(2) Incentives: No surprises here - we all know a system gets what it is designed to get, and right now, our healthcare system reimburses based on volume over value, and quantity over quality... and the former is pretty much what it gets. So clearly we need to create a reimbursement system that rewards physicians for value and quality... and if they achieve these things, they should get those rewards whether they use EMRs or not (but I suspect it will be easier to do this with EMRs than without). I think the HITECH bill is a positive step and truly a "stimulus", but we still need to figure out how to improve long term, day to day reimbursement to make sure doctors are rewarded for doing the right thing.

(3) Interface ("User interface" or "Usability"): This third point has always held great interest for me, since I have often had to use the systems I build. So I feel the pain when it takes 25 clicks to refill a med because EMR vendors still don't seem to understand that for me to refill a med, there is a ton of contextual data needed. For example, I need to know: what I was thinking at the last appointment (e.g. did I tell the patient to return in 3 months, and it has now been 5 months without a return), do they have an upcoming appointment, did the labs from the last visit alter my thinking on their follow-up, or has anything happened in the interval. In a typical EMR, I need to click all over the place to find this information - how come it can't just bring it all to me (answer- technically it is possible, but the EMR vendors just don't seem to get it).

This idea that the EMR needs to pull together and present "what we need to know and what we can do" is a recurring theme in my diatribe on Usability - the screen shots for specific workflows (e.g. med refill, lab review, phone message, office visit) should consolidate all the information I would likely need to review to complete that workflow (e.g. meds, labs, visit dates, notes) - ideally in a manner that is easy and quick to read: "Data visualization" may include graphics or other data manipulation (e.g. calculate the anion gap, or the Total/HDL values for me). Furthermore, the EMR should predict what I might want to do next and offer up those options to me (e.g. refill a med, order another potassium test, etc...). The result is LESS CLICKS - I don't need to go looking everywhere for data or orders- the EMR has brought them to me!!!

I talked in depth on this topic at the recent HIMSS conference and hired several graphic designers to actually build out some of these concepts as either screen shots or flash animation - these are by no means perfect, but they give some sense of interfaces that take advantage of how an EMR can make workflows easier. They will hopefully stimulate more thought and ideas in this area. The PPT below provides a summary of this talk (although I could not figure out how to upload the flash applications - so it will all be static screen shot here). I used SlideShare to upload the PPT and embed into Blogger:

Improving EMRs 2009

View more presentations from Lyle Berkowitz, md.

Post-Blog stories of interest
Wired magazine "re-imagines" lab reports: http://www.wired.com/magazine/2010/11/ff_bloodwork/all/1