Better Care Through HCIT 101: Part Three, Go-Live is the Springboard to Achieving Benefits - Choosing goals that deliver benefits

• Go-Live should be the Springboard to Achieving Benefits
• Choose goals that deliver quantifiable benefits
• Meaningful use should be linked to quality/cost/access?

What can your clinical information system do to improve health in your community? Ten years ago, you might have had to stop and think a bit. One year ago, your first sentence would probably contain the word "Safety" or the words "Patient Safety." The thought behind that would have included "integrated" medication management; its specifics would have included BCMA and CPOE. The discussion itself is problematic and inherently private -- no one is going on TV to tell the world that their institution had 10 avoidable deaths last year. Next year, your answer will likely be informed by ARRA. The vision: increase coverage and lower healthcare costs, using an EHR in which qualified providers can demonstrate meaningful use, and the EHR is certified. We're hopeful that meaningful use will tie back to last year's "Safety" through ePrescribing and it's in-patient analogue, CPOE. Okay, we're all, I presume, on the same page for vision. The immediate realities for clinical HCIT include everything around the basics - a problem list and it's cousins, the medication and allergy lists. Forget about the rest of clinical documentation for a moment. We all know how very specific test cases can create instant clarity on our real current state and the cost and timing of getting to a desired state. I've written previously that a powerful test case for EHRs is support for Coumadin management. This translates to probes for vendor selection, specific capabilities of flowsheets, order sets, and care pathways. No vendor I've seen would get a perfect score, or even a near perfect score, when you look at the TOC (total cost of ownership) for HCIT and Coumadin management. Oh, by the way, for the last decade Coumadin and related products have been the number one medication safety issue, at least in hospitals (see MEDMARX). So, Coumadin covers the broad category of a test for drug safety. There are easy and obvious equivalents for diagnosis (service line, disease, condition) where Heart Failure serves well. And for process and workflow support, the pre-op surgical assessment is extremely effective. Combining clinical information completely in these examples continues to be challenging. Although several vendors have made huge strides forward in their 2007 and 2008 code, the TOC remains absurd for these common categories of clinical HCIT enablement. Today, I'd like to suggest diabetes detection and management as the best, patient-oriented test case for meaningful use of HCIT. I was inspired by the recent article, HbA1c Gains Legitimacy For Diagnosis of Diabetes, by Mitchel Zoler (Internal Medicine News, March 15, 2009.)

Advances in the diagnosis of Diabetes

Making HbA1c an accepted diagnostic test—let alone the preferred test—has been on the table for years. At a recent meeting sponsored by the ADA in New York, Dr. William C. Knowler spelled out the case in favor of using glycosylated hemoglobin, as well as the shortcomings of this approach. The strengths of HbA1c as a diagnostic tool include the following:

▸ A more standardized assay with less interlaboratory variability, compared with blood glucose measurements.

▸ A better index of overall glycemia.

▸ Consistency in using the same assay for diagnosis that's also routinely used to monitor patient treatment and to predict the risk for long-term complications.

▸ No need for fasting before the specimen is drawn.

▸ No effect from acute changes in blood glucose levels, such as those caused by illness.

In short, there's a relatively new, legitimized way to screen for diabetes. It has lower costs than current testing. It has the potential to make increased population coverage more affordable for this huge segment ( Diabetes has a 4% to 10+% prevalence, much higher in Medicare-age population, with huge opportunities for cost savings.). Subsequent diabetic management is well known to be considerably more cost-effective than the alternatives. Clinical HCIT has one of the largest opportunities to drive meaningful use to meaningful results (national coverage and costs) by demonstrating improvements in identifying and managing Diabetics. I know that I'm not the first to identify this public health use case. But I find it noteworthy that the monetized value of health reform rarely, especially the ARRA-2009 definition development process, elaborates these kinds of hard disease/hard dollar issues. Conclusion and Lessons? When looking at the ARRA-2009, or any other improvement initiative, you can now ask: Specifically, how does this definition, for example, meaningful use, translate into increased coverage, or decreased costs with the same or better quality of what it replaces? (By the way, many leaders, like those at AHRQ, consider safety a sub-domain of quality.) Questions like, W hat is the prevalence of the condition (patients, people or citizens impacted), what is the specific impact on costs to diagnose and treat, and what are the specific roles and responsibilities of the EHR?, need to be clearly laid out. Much of the criticism to date will melt away when well linked goals and meaningful use definitions for EHRs are published. There's nothing vague or economically insignificant about the impact of diagnosing and treating diabetes more effectively using EHRs.