Tuesday, January 6, 2009

Let's Reboot America's HIT Conversation--Part 2: HIT Beyond EHRs

Let's Reboot America's HIT Conversation
Part 2: HIT Beyond EHRs


Yesterday we tried to put EHRs into perspective. They're important, and we can't effectively move health care forward without them. But they're one of many very important HIT functions, and EHRs and HIT alone won't fix health care. So developing a comprehensive but effective national HIT plan is a huge undertaking that requires broad, non-ideological thinking.

The danger we face now in developing health care solutions, as we've learned so painfully elsewhere in the economy, is throwing good money after bad. We don't need merely a readjustment of how health IT dollars are spent. We need to reboot the entire conversation about how health IT relates to health, health care, and health care reform in this country. To get there, we need to take a deep breath and start from well-established and agreed-upon principles.

Most of us want a health system that bases care on knowledge of what does and doesn't work - i.e., evidence - whenever possible. We want care that is coordinated, not fragmented, across the continuum of settings, visits and events. And we want care that is personal, affordable and increasingly convenient. Most of us agree that, so far, we have not achieved these ideals. In fact, health care continues to become costlier, quality is spotty, and the gap between the health care we believe possible and the current system is widening.

We believe that most health care professionals are acutely aware that HIT alone cannot resolve these problems. Despite billions of dollars in HIT investments by health care professionals and organizations, the gap persists and is widening. Many physician practices have expanded their HIT functions, moving beyond billing systems - a necessary asset to be paid by Medicare - towards EMRs and from paper to software systems. About a quarter of US physicians use EHRs from commercial vendors. Hospitals and health plans - larger, corporate organizations with more dedicated capital resources - have implemented HIT more quickly. Even so, the tools implemented have typically been focused on recordkeeping and transactional processing, not decision-support. Health care clinical and administrative decisions have not yet become more rational, less tolerant of waste and duplication, or more congruent with evidence. We don't just need more HIT; we need an array of specific functions that can facilitate better care at lower cost in a complex, wasteful system that currently adheres to few evidence-based rules.

What would those better HIT products look like, and what would they do?

Focus on Decision Support
Most important, new HIT would help clinicians, managers, purchasers and patients make the best possible clinical and administrative decisions. This includes identifying risks and following the best path to lowering them whenever possible. In other words, HIT should help people stay healthy and avoid illness through active clinical decision support, and make sure that the system recognizes value. Which patients, according to past data, have chronic or acute conditions that need care? Which, do the data show, are the most effective (or high value) doctor, hospital service, treatment, intervention - so that the market can work to drive efficiency. Given a particular set of signs or symptoms, what is the best next step in care?

Technology and information engineering is readily available to do this. Car technologies now help drivers understand when a problem is occurring, or is likely to occur, monitoring fluid levels, tire pressure, maintenance appointments, and location in case of emergency. Banking technologies can flag suspicious credit card purchases and can instantly invalidate charge cards. Recently, Google trended flu searches to help estimate regional flu activity; their estimates have been consistent with the CDC's weekly provider surveillance network reports.

By comparison, most HIT is relatively unsophisticated. In general, the prevailing frontline tools do not yet help clinicians identify individual- or population-level health risks. They don't yet provide guidance with evidence-based approaches that can best mitigate those risks, or help monitor adherence to care plans, even though the data are now clear that most Americans die and we pay the most money due to easily preventable and managed conditions.

In short, we monitor our cars and bank accounts better than we do our health. We can change this.

Untethering Patients with Easily Accessible Personal Health Information
High value HIT would improve care by making summary personal health information available, increasingly independent of location and time. Most health records are still tied to a health care organization's data center, supporting an outdated business model in which the patient must come to a centralized, expensive location for even the most routine tasks, like history-taking or lab testing. Most current EHRs don't change this, in large part because they aren't connected to the Internet. Web-enabled patient information would untether the patient, and make increasingly standardized care more readily available anywhere. De-coupling health information from health care providers is the first step in the development of new business models that will offer team-based care services wherever one is located, saving money and increasing convenience.

Empowering Patients Through Online Linkages with Clinicians and Other Patients
HIT will link patients with clinicians, will match problems with most appropriate solutions, and will use social networking to increase access to patient- and condition-specific information, knowledge, and guidance. This class of HIT applications will be particularly useful with chronic illness, shifting more of the condition's monitoring and management to the patient and his/her family and peers, with diminished reliance on the office-based physician. Bringing advances like these to fruition will require much broader implementation and access to broadband technologies, as well as standardized health record formats.

Participatory Medicine: Bridging the Medical Home and Web-Based Care
As Kibbe and Kvedar recently wrote, much of the HIT we're describing bridges the divide between two powerful trends: Health 2.0 (or user-generated health care ), and "the medical home." It is now clear that, while most health care consumers want to be more actively engaged in their own care management - e.g., using Web-based search and joining patient communities - they also want to be connected to their physicians for questions and care when appropriate. The way forward here is participatory medicine that combines and remixes health information and knowledge - some from experts and some from the crowd - in the interest of helping us live healthier lives. Here is a very good description from a practicing pediatrician about how this will work:
...organized medicine needs to provide the day-to-day support patients need to prevent disease and to self-manage their conditions if they are ill. In the connected era that means just in time delivery of the personalized and up-to-date data and information a person needs to have the knowledge to make wise choices. It means supporting patients to easily and accurately keep track of their performance. It means providing tailored messages and experience that speak to each person based on their unique characteristics, their performance on key behaviors and their needs at that moment in time. It means helping patients link directly to family and friends for critical support, and link to their many providers to help integrate medical care with everyday life.
Data and Accountability
HIT can help make all health care professionals and organizations - physicians, hospitals, other providers, health plans, drug firms, device firms - more accountable for quality, safety, and cost results, and for the engineering required for continuous improvement. We can learn from our current supply, care delivery and finance processes in the same ways that Toyota and Wal-Mart monitor their internal business processes. The problem is not just that we lack some important data elements to carry out these analyses now. More to the point, we have not committed nationally to aggregating, analyzing, and reporting the massive amounts of health data that we already have. Similarly, due to a lack of incentives and competing interests, most professional and organizational health care players have resisted using data to improve the quality, safety and cost of American care.

Closing the Collaboration Gap
Finally, a new generation of HIT capabilities will close the "collaboration gap" that exists between the system's many sequestered players, who as a result perform so much less effectively and efficiently than they otherwise might. Clinicians, for example, diagnose disease and set up treatment plans but often are isolated from helping their patients cope, manage, or adhere to these plans. Patients, once diagnosed, are motivated to manage their illnesses but often have few tools or methods to assist them. Purchasers and payers want to see clinicians use the most efficacious resources, but typically do not have a way to inform and reward evidence-based purchasing processes. In every case, HIT can facilitate a more collaborative experience that is tailored to the user's purpose, no matter what role that user plays in vast health care space.

HIT presents enormous, unprecedented opportunities to improve the quality of care, to dramatically reduce the waste and cost inherent in our current approach, and to culturally transform patients to become more actively engaged in their own health and care. Bringing the fluidity of knowledge and data to fruition will allow us to leverage the true power of information, and that can take many forms. The real HIT challenge to the Obama health care team is to step back, take stock of the kinds of applications that are emerging in HIT, and create an expansive, open policy structure that can leap beyond the status quo and really change the way American health care, in all its facets, works.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies. Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc.
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