Let's Reboot America's Health IT Conversation Part 2: Beyond EHRs

By DAVID KIBBE and BRIAN KLEPPER

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 only one of many important health IT functions. EHRs and health IT alone won't fix health care. So developing a comprehensive but effective national health IT plan is a huge undertaking that requires broad, non-ideological thinking.

As we've learned so painfully elsewhere in the economy, the danger we face now in developing health care solutions is throwing good money after bad. We don't merely need 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. 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, whenever possible, bases care on knowledge of what does and doesn't work - i.e., evidence. 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 also 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 more health IT alone cannot resolve these problems. Despite billions of dollars in health IT investments by health care professionals and organizations, the gap persists and is widening. Many physician practices have expanded their health IT functions, moving beyond electronic billing systems - a necessary asset to be paid by Medicare - toward 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 health IT more quickly. Even so, the tools implemented have typically been focused on record-keeping 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 need simply more health health IT; instead, we need an array of specific health IT functions and capabilities that can facilitate better care at lower cost, and the adherence to evidence-based rules.

What would those empowering health IT products look like, and what would they do?

Focusing on Decision Support
Most important, new health IT would help patients, clinicians, managers and purchasers make the best possible clinical and administrative decisions. This includes identifying risks and following the best path to lowering them whenever possible. Health IT 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 acute or chronic conditions that need care? Which, do the data show, are the most effective (or high value) doctors, hospital services, treatments and interventions - so that the market can work to drive efficiency.  Given a particular set of signs or symptoms, lab test results, or genetic test, 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 and communicating 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 health IT is relatively unsophisticated. In general, the prevailing front line tools do not yet help clinicians identify individual- or population-level health risks. They do not yet provide guidance with evidence-based approaches that can best mitigate those risks, create alerts and reminders, 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 health IT would improve care by making summary personal health information available to providers and patients, 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 yet. 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
High value health IT will link patients with clinicians, will match problems with the most appropriate solutions, and will use social networking to increase access to patient- and condition-specific information, knowledge, and guidance. This class of health IT applications and services 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 and the single visit model of care. Bringing advances like these to fruition will require much broader implementation and access to broadband and mobile technologies, as well as standardized health record formats that use XML, like the Continuity of Care Record (CCR).

Supporting Participatory Medicine: Bridging the Medical Home and Web-Based Care
As Kibbe and Kvedar recently wrote, much of the health IT we're describing here 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 Neal Kaufman, MD, a practicing pediatrician and the CEO of DPS Health, 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.

Making Data and Accountability the Routine By-Product of the Use of Health IT
Health IT can help make all health care professionals and organizations - physicians, hospitals, other providers, health plans, drug firms, device firms - more accountable stewards 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. 

But we need to design data aggregation into the products from the start, not as an afterthought. 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. 

Interoperabilitiy of various EHRs is absolutely critical to the ability to cost-effectively collect, manage, and report outcomes data.  All health IT products used in the care of diabetic patients, for example, ought to be required to export performance data relevant to care of diabetes in standardized formats.  All research of any kind depends on this capability.

Removing the Complexity and Cost Associated with Multi-Payer Claims Administration
Health IT ought to make claims payment, eligibility look-up, co-pay verification, and other administrative processes simpler, easier, and faster for providers, patients, and family members.  There is no good reason why we don't currently have an all-payer clearinghouse for patient administrative and financial information that is standards- and web-based. There also is no good reason why, in the era of PayPal, physicians and hospitals experience Days in Accounts Receivable of 36 and 55, respectively. As Rick Peters has written recently, it is time for us to build a scalable, XML, and cloud-based claims adjudication, public health, and quality reporting system to replace the entire archaic mainframe systems at CMS and their fiscal intermediaries. "Make the winning solution open source, implement it for Medicare and the CDC, and offer it free to every state Medicaid program and all the commercial payers," he says, and we agree it is time to use updated technology to resolve the inexcusable claims administration mess.

Closing the Collaboration Gap
Finally, a new generation of health IT platforms and services 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 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, health IT 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.

Health IT 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 physicians and patients so both become more actively engaged in improving health and health care. Bringing the fluidity of health information and knowledge that is just starting to fruition will allow us to leverage the true power of information engineering, and that can take many forms.  We think the name "clinical groupware" is more appropriate to this new class of health IT products and services than is the term "EHRs."  In any case,  the real health IT challenge to the Obama health care team is to step back, take stock of the kinds of applications that are emerging in the domain of health IT, including EHRs, 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.