Implementing EHRs Requires a Shift in Thinking

June 1, 2006

PHRs—the building blocks of EHRs—may be the quickest path to the fulfillment of disease management.

During the past 20 years, physicians have seen amazing advancements in technology and have witnessed their beneficial impact on the health and the lives of hundreds of patients. They have also seen the amazing impact that sound information can have on a patient’s health and on the decisions made regarding that patient’s care. While society as a whole has never been more connected, more integrated, more technologically advanced or more global, healthcare still has some fairly old-fashioned mores that must be challenged and reshaped to truly advance electronic health records (EHRs) on a large and sustainable scale.

PHRs—the building blocks of EHRs—may be the quickest path to the fulfillment of disease management.

James Pope, M.D., F.A.C.C., is executive vice president, chief medical officer at Healthways Inc., headquartered in Nashville, Tenn.

During the past 20 years, physicians have seen amazing advancements in technology and have witnessed their beneficial impact on the health and the lives of hundreds of patients. They have also seen the amazing impact that sound information can have on a patient’s health and on the decisions made regarding that patient’s care. While society as a whole has never been more connected, more integrated, more technologically advanced or more global, healthcare still has some fairly old-fashioned mores that must be challenged and reshaped to truly advance electronic health records (EHRs) on a large and sustainable scale.

Physicians have for so long been the ones in control of the medical record, that delegating or sharing any of that responsibility will require as much of a shift in thinking and training as it will in systems. Likewise, patients are used to—and, in many cases, are still very reluctant to shift away from—the notion that “doctor knows best,” despite the fact that best practices are provided only about 50 percent of the time.

Add to that the fact that personal health information is usually dispersed among multiple providers and participants. Health plans, generalist and specialist physician offices, hospitals, laboratories, pharmacies, pharmacy benefit managers and disease management organizations all collect some (and sometimes duplicative) information.

Paradigm Shift
In particular, patients with chronic illness (and their caregivers) need access to their medical information to actively manage their conditions in collaboration with their practitioners. But the reality is, patients typically don’t have easy access to such information—nor do they always know they need it. Patients need tools to integrate and manage all of their information across all providers and across time. Practitioners are poorly prepared for the necessary and imminent shift in information collection and management, collaborative patient participation and, ultimately, patient control.

Some providers, however, can play a significant role in setting the stage for what will be a huge paradigm shift in healthcare where patients move from peripheral positions of decision making to central positions of decision making and information control. It can all start with a simple, patient-controlled personal health record (PHR). A PHR can be written down on paper and kept in a file or it can be kept on a home computer or PDA. No matter how simple or complex, though, patients and physicians will need some guidance getting started and keeping going.

Disease management companies are uniquely positioned to facilitate both greater electronic connectivity between multiple providers and patients/caregivers, as well as to help the patient and practitioner make this necessary and imminent shift. As experienced health coaches with access to a broad array of clinical information, disease managers can teach patients how to be the model patients for the 21st century—fully informed, involved patients managing their health conditions in collaboration with their practitioners. Disease managers already help patients, physicians and other members of the care team know the right questions to ask each other and help keep track of a patient’s care, their test schedules, their doctor’s appointments, their medications and other life issues that affect their health.

The physician consensus report, “Improving Care Coordination Through Physician/Disease Management Collaboration,” recently identified this team approach as a critical support piling in the bridge across the healthcare quality chasm. The report, released following the 5th Annual Johns Hopkins/Healthways Disease Management Outcomes Summit of more than 200 practicing physicians, found that physicians and other caregivers must motivate the patient to change behaviors. They must also allow and encourage the patient to become part of the healthcare team. This requires a change in the way both caregivers and patients approach the very concept of healthcare.

Healthcare Team Is Vital
The outcomes summit report endorsed a wider adoption of the concept of the “healthcare team.” It concluded that while achieving care coordination will require time and significant investments in technology and other infrastructure, substantial improvements can be realized in the near term by more effective collaboration between physicians and existing health and/or care support services, such as disease management programs. If done effectively, care coordination puts patients at the center of the care process, encouraging engagement as well as responsibility. It also fosters the team approach, and ensures continuity of care across time and settings.

This healthcare team approach is vital to the success of EHRs and vice versa. Despite the lack of decision- or health-support systems in healthcare today, patients and physicians alike are being held increasingly accountable for the healthcare decisions they make. Yet both lack access to the broad array of information in healthcare—including specific clinical and patient information, practice guidelines and drug interactions—that are critical at every point of decision-making and care to provide the best possible outcomes. To date, research confirms that there is no single entity in our increasingly complex, fragmented and pluralistic healthcare system that is capable of, or responsible for, collecting and maintaining all of the important health information about any one individual.

This is also why the concept of the PHR is so vital. This is a patient-controlled record that can be collected and maintained either manually or electronically through existing software. The PHR travels with the patient, and it serves as a building block to an EHR, which is much closer at hand for large group practices and integrated health systems than it is for the majority of physicians who work in practices of 10 or fewer. This small-practice setting, however, also is where the majority of care is traditionally delivered and coordinated.

Compared to the technological complexity of creating standardized electronic medical records (EMRs) or EHRs, the development of personal health records is relatively simple. A PHR (such as the Savard System) is a collection of important information about a patient’s health and family medical history and includes current medications and their dosages, immunizations and their dates, allergies, test results, recent surgeries and health insurance information. The patient actively maintains and updates the PHR at all times, and the information comes from the patient as well as other members of the healthcare team.

This kind of information can be a critical aid at the point of care to the members of the healthcare team, especially the physician. PHRs, compared to EHRs, however, can be implemented rapidly, with very little cost and can serve to keep patients fully engaged in their own healthcare. As a result, they can help affect behavioral change toward healthier lifestyle decisions. This, in turn, begins to set the stage for the kinds of far-reaching behavioral changes that must take place in any system that successfully implements and utilizes EHRs.

Disease Management as an Avenue
Most disease management organizations already collect vast amounts of clinical information and put it in the hands of patients and physicians in ways that patients can understand and physicians and patients can use. They can serve as the conduits of electronically collected, organized and stored clinical information to practitioners and patients, thus helping them build and populate their EHR/PHR. By its very nature, disease management supports and enhances the patient-physician relationship and educates people with chronic conditions about the best ways to partner with their physicians and optimally manage their diseases. Unlike the limited time patients have with physicians, disease management is a resource and a support system that’s available 24 hours a day, seven days a week, 365 days a year.

As noted in the physician outcomes summit report, “Various disease management strategies have emerged as significant contributors to care and quality improvement by providing information and technology infrastructure to connect with patients, manage data and integrate information on services provided to patients across care settings. The extent to which further integration of these strategies with other components of the health care team and system will determine the extent to which additional progress toward the goal of care coordination is made.” Also, the pace with which PHRs, and ultimately EHRs, are developed and deployed is relative to the progress toward ideal care coordination. How fast such solutions are deployed, however, relies less on available technology than it does on available funding.

Incentives
Systems, solutions and compensation must all be aligned around outcomes if they are going to succeed. Healthier people cost less. If the health and the quality of life of one person improves, that person’s overall healthcare costs are lower. Healthways only gets paid if it improves patient health, increases patient and physician satisfaction and reduces total healthcare costs. With those metrics in mind, the company has worked with several health plans to pilot physician pay-for-performance programs. When entire healthcare teams are aligned, patient health improves dramatically. Patients are healthier, more engaged and more satisfied with the healthcare system and doctors get the support and incentives necessary to help drive better outcomes.

Even today, many physicians still don’t have the technological infrastructure to support the demands of the modern healthcare system and the modern healthcare consumer, much less take on additional information from other sources. Recent reports indicate that fewer than 15 percent of all physicians use the advanced technologies available, mostly because they are cost prohibitive, but also because of the uncertain return on investment and the inherent difficulties associated with implementation.

Much of that will change as the federal government pursues various solutions, incentives and changes in reimbursement policies. While disease management companies are already heavily invested in state-of-the-art technologies, they must do a much better job of leveraging technology to meet the needs of physicians and patients and work even more closely with them moving forward.

There also should be incentives to help physicians make the investments necessary, such as low interest loans or grants or financial incentives to promote collaboration of physicians within local geographical regions. Patients, on the other hand, need incentives to participate in their own healthcare and to take the types of preventative steps that keep them healthy and out of the hospital. Health plans can provide discounts for patients who participate in maintaining a personal health record, or who choose to see physicians participating in multipractice collaboration.

Personal Story Within Every EHR
As EHR standards are developed and interoperability comes into play, technology must facilitate easier and more intuitive use of the various healthcare tools and information already in existence. Technology can also help spread the understanding of and interest in using PHRs on both the side of the patient and provider.

The PHR can be a powerful and inexpensive tool to help drive the shift in thinking that will be necessary to truly transform the healthcare system and the ways in which we interact with it. It can serve as the “personal” story within every EHR, capturing the important life issues that can easily get lost in an electronic record geared solely toward typical healthcare data. What physicians, patients and their caregivers need most are tools and systems to help them cut through the clutter of modern society and focus on what’s important at the moment decisions are being made and care is delivered.

Just making medical records available electronically isn’t going to do it. Patients must become engaged and involved in their own care. PHRs encourage that, but healthcare consumers must be taught how to start and keep track of their PHRs. Physicians need support to track and follow up with patients between office visits. The good news is that work has already begun, and it doesn’t have to wait on the development of widespread, widely adopted EMRs or EHRs.

For more information about services from Healthways Inc.,
www.rsleads.com/606ht-201

June 2006

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