Getting to “The Good Stuff” on EHR Development

April 10, 2013
As Accenture’s Kip Webb, M.D. looks at the uptake curve around EHR adoption and clinical transformation, he sees a minority of patient care organizations nationwide whose leaders have taken them beyond first-stage implementation and into true clinical transformation—and a worrisome proportion of patient care organizations that are still struggling through the adoption/implementation phase

Kipp Webb, M.D., M.P.H., is the executive director of Accenture Clinical Services, the global clinically oriented healthcare practice of the New York-based Accenture. Webb, who with his team is San Francisco-based, spoke recently with HCI Editor-in-Chief Mark Hagland regarding his perspectives on the current level of EHR implementation and beyond, to true clinical transformation. Below are excerpts from that interview.

When you look at the nationwide landscape of EHR adoption and clinical transformation, where in your opinion are the most advanced organizations now in terms of EHRs?

We’re really only still in stage 1 as an industry, in terms of the HIMSS Analytics EHR adoption schematic. The most advanced organizations really are leveraging data for performance improvement. But some are chugging along where they should be, towards true clinical transformation.

Kipp Webb, M.D.

But don’t you worry that the ones in stages 1 and 2 are terribly behind where they should be?

Oh, absolutely. As of Q1 of calendar year 2012, only 30 percent of hospitals were in stage 4 or above, according to the HIMSS Analytics schematic. Still, in context, that’s fantastic; three years ago, we were at something like six percent, so 30 percent represents an enormous improvement. However, we’re still stuck at that stage 3 cliff, where they have nursing documentation, but not yet CPOE, which is a stage 4 process. So you have the physicians now all of a sudden active creators of data in terms of CPOE at stage 4 and physician documentation at stage 6. And some hospitals either lack the robust technology they need for those stages, or they’re afraid to take on the physician community.

And HIMSS doesn’t present it as a curve, but you can imagine it as a curve, with a big spike of hospitals in stage 3, but a big drop-off after that. Some hospitals just have not been able to take the plunge and get over it. And whether it’s the EMR vendors’ fault or the physicians’ fault or a lack of funding or of IT staff, they’ve been unable to go the next mile, which is where the good stuff happens.

But once we get into stages 4 and higher, that’s where the good stuff really happens. And tying it back to the meaningful use stage 2 goals, really, in terms of data-enabled clinical process improvements, we’re talking about workflows and making them more streamlined and efficient; and you can improve outcomes and most certainly eliminate waste, at that point. And in terms of clinical decision support… And care coordination would be the other place, whether we want to call that medication reconciliation, or whatever we call it… we’re starting to see some of that. And the last part of that is feedback, the analytics portion of this. How do we give physicians real-time feedback, to better encourage compliance with processes, etc. We’re beginning to see examples of that all over the place now. And we’re starting to be asked more and more to help optimize EMR. And we’re seeing from a lot of vendors, just install it “vanilla” and then customize. They’re saying, we can install it more reliably and more cheaply if you just follow our rules. And the vendors are right; I agree with them on that. But it’s almost a false bet. Because you’re saying, aha, great, I can install it faster and get my meaningful use dollars more quickly. But they’re not getting the process improvements called for in stage 2 or the clinical outcomes improvements called for in stage 3. So it’s complex. You really need to engage the doctors in some nimble governance or new rules they need to follow in terms of care delivery and standards of care, etc., that historically have been the last thing to come.

Do you see any particular direction in terms of teams of clinical informaticists? What are your thoughts in that area?

I do. What I’m seeing is the informaticist role being a very tactical role, that my constituents have a problem, and whether that particular problem is a misfiring alert, or a workflow problem, or an outcomes goal, that is the kind of activity that most of these clinical informaticists are taking on right now. And in an electronic data and sharing world, that’s probably OK. But what I’m not seeing yet is how, in the long run, how we’ll be supporting real improvements in care, across roles and settings. And unfortunately, some of the things you can do within the EHR application, by the time you get to stage 3, intra-EHR isn’t going to work; you’re going to need other systems and analytic capabilities built on top of the EHR. All the EHRs have been designed for one purpose, which is the delivery and documentation of care for individual patients, but not for another purpose, population health management. So we’re going to need new tools.

And the other problem is that today’s generation of clinical informaticists is largely tactical and not strategic; but we’re blessed at Accenture with some clinical informaticists who understand ontologies and data warehouses. And in other countries, such as Singapore and Australia… We’re putting together an Australia-wide patient-controlled personal health record. And how do you capture patient data for meta purposes? In the United States, we’re just beginning to scratch the surface there. I was talking to someone yesterday about Epic and their CareEverywhere, and they’re purposely not calling it a tool for HIE, because they don’t want to have to deal with 50 different sets of state regulations. So we’re moving forward with countries like Australia and Singapore.

Of course, the healthcare system is moving towards accountable care in the broadest sense of that term, correct?

Yes. And think of the components there: we need healthcare policies and reimbursement schemes to support the new healthcare—people have got to get paid. And we’re moving in that direction, as long as the Supreme Court doesn’t derail us on the ACA. Second, you need base systems to support all this—not just EMRs, but billing systems, revenue cycle management, and analytics, to understand how to support those models of care delivery. And finally, you need the clinical leadership to support new models of care delivery. And is there any place in the United States that has all three ingredients? And the answer is, yes, at Kaiser and Geisinger and Group Health Cooperative and Mayo—and whether it’s patient-enabling technologies to help patients take better care of themselves, or tools to support population health management tools, those are emerging, as well as technologies to support team-based health. And the work going on at Group Health and Geisinger is so exciting in that respect. The thing is, if you’re not those groups, there are many other groups—Ascension, Sutter, Dignity Health, etc.—and they’re all saying, regardless of what happens with the Supreme Court next month, we’re not going back, because our patients need it, and frankly, payers are demanding. So we’re moving forward with the direction of the ACA; and so that’s exciting.

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