Better Care Through HCIT 101: Part Two, What Problem Does the EMR Address?

In this crazy era where we’re going to “fix healthcare” by driving investments into adoption and meaningful use of an EMR, there’s a vague fog about what exactly this will fix. When the certification criteria become established for ARRA, we’ll be in a better position to clear the air. In any event, it will help, both before and after these are defined to have a framework to think about fixing healthcare. Why a framework? A framework can help sort issues into a succinct, manageable package, allow priorities to emerge, required sequences to become apparent, and allow for a complete argument to be constructed. The kinds of frameworks I’m talking about are simple and elemental. For example, a SWOT analysis or applying Michael Porter’s “Five Forces of Business Competition” come to mind. They allow an intelligent person to quickly and succinctly organize an argument and have an assurance that it’s reasonably complete, at least in terms of the framework. Are there commonly accepted frameworks for fixing healthcare? Frameworks that are useful, especially with respect to contextualizing the impact EMRs will have on healthcare? Well, here’s a brief story to illustrate one framework and help make it memorable. I call it The Vowels of Healthcare Improvement.A few years back, the U.S. Surgeon General at the time, C. Everett Koop, said that healthcare problems, and the solutions to those problems, could easily and succinctly be summarized. Using some literary license, I organized those problems (issues) as follows: Administrative costs are too high.Effectiveness is not a focus. We over use, under use and misuse resources. Incentives are aligned for the volume of care, not the value of care. Outcomes are not systematically captured and used for learning. Uninsured care causes very irrational behavior, cost shifting, overall waste and suffering. The vowels A, E, I, O, and U are easy to remember and easy to remember in order, thereby serving as a memory aid to discuss these issues. I generally don’t disclose that the mnemonic device is there until after the audience has agreed that the five issues are generally recognizable and probably the most important. The vowels also closely correlate to the natural sequence of healthcare improvement. This sequence starts with reducing Administrative costs by becoming focused upon finding and moving information electronically. Whether that’s reconciling a patient’s identity, viewing an electronic medical record, ensuring adequacy of the record (medically, financially, legally), or submitting a bill (claim), EMRs and the associated transaction solutions drive down administrative costs dramatically. The comparative costs, for example, to pull a patient’s record, find the information required, and re-file the chart typically costs institutions $10-$30 per paper chart pull, and introduces 15-30 minutes of process delay waiting for and handling the chart. Waiting for a paper chart to be delivered, or walking to radiology to see a film, were common frustrations for me. But with strong EMR solutions, these costs become pennies and the delays are measured in seconds, usually less than ten seconds. What’s amusing is that most of us complain that waiting ten seconds for an electronic document to open is an eternity, even though the processes being replaced were measured in tens of minutes! EMRs play a comparable role to improve, once decision support is applied, Effectiveness, Incentives, and Outcomes. And, until good and appropriate processes are made more automatic, we won’t be able to systematically plan, deliver and cost care effectively enough to develop a sustainable economic model that addresses the Uninsured. There are other components of the sequence that have obvious sequential aspects to them as well. For example, we cannot assess Outcomes effectively if they don’t reflect repeatable processes. Call those processes guidelines, order sets, knowledge management or workflow. Yes, we know those are all different, yet they each reflect program components we all recognize as essential to ensure the care provided reflects what the best of us know about diagnosis and treatment.Notice that payment, privacy, standards, certification, and other important elements are secondary to the EMR and transaction machinery addressed by the Vowels. Conclusion and Lessons? When looking at the stimulus package, or any other improvement initiative, you can now ask: Specifically, how does this lower Administrative costs? Will these Incentives, for example, improve Effectiveness of care, or merely automate existing practices? Will these Incentives have a direct impact on Outcomes? Will they, through the earlier vowels, better position us to improve Outcomes in the future? And how will these measures impact the Uninsured, and when? This framework has proven to be a very effective communication tool, while keeping the focus on nobler motives. I hope you find it useful as well.