P.74
Catheter-associated urinary tract infection X X X
Surgical site infection (SSI): X X
SSI following colon surgery
SSI following abdominal hysterectomy
Methicillin-resistant Staphylococcus aureus (MRSA) X
Clostridium difficile X
It is believed that the results from the demo project will provide clarity around many of these issues, although one could argue that obstetrician-gynecologists have been doing bundled payments for obstetric care for many years.
In addition to the previously noted problems with payfor-performance programs, another limitation is that most programs to date have focused on single disease states or outcomes (such as immunization or Pap test or mammogram compliance). In reality, many patients aged 65 or older have multiple medical problems and treating single disease states in isolation may not lead to overall improved outcomes and enhanced quality. It is not surprising that 89% of Medicare's annual budget is consumed by patients with three or more chronic conditions.
Boyd et al. evaluated current clinical practice guidelines (CPGs), which are often used in pay-forperformance programs, but which also focus on single disease states. In a hypothetical 79-year-old female patient with the common comorbidities of chronic obstructive pulmonary disease, diabetes, osteoporosis, hypertension, and osteoarthritis, they found that following each CPG would lead to 12 prescribed medications and a potential outlay of $406 per month. There were also significant issues with the potential for drugdrug interactions if this “optimal”
regimen was followed. They concluded that pay for performance based on CPGs for single disease states may create “perverse incentives” and actually decrease quality of care and that significant effort should be placed on effectively treating the multiple chronic conditions that many of our patients have.
While these initiatives are only still beginning, there will likely be future pressures both at the state and federal level to achieve an ever-higher level of quality. In addition, pay for performance needs to evolve to incorporate these early findings into rationale paradigms for physicians, which align the needs of our patients, payers, and providers. It may also become quite difficult for groups and practices that do not have access to electronic data to be able to participate in such projects.
P.75 FIGURE 5.4 Meaningful use roadmap.
In many areas of the United States, much of this has changed. Numerous opportunities exist with the EHR to overcome many of the technical issues associated with handwriting, but the opportunities go well beyond legibility. In addition, groups like the American Medical Informatics Association's College of Medical Informatics has called for integration of the EHR and personal health records (PHR) to provide the greatest value for our patients. Much of the current focus on EMR implementation is being driven by the billions of dollars available to providers who can attest to “meaningful use.” The American Recovery and Reinvestment Act (ARRA), which was enacted in 2009, includes the Health Information Technology for Economic and Clinical Health (HITECH) Act, wherein meaningful use in three separate stages is called out (Fig. 5.4). Incentive payments range from $44,000 over 5 years or $63,750 over 6 years to providers attesting to Medicare or Medicaid, respectively (Fig. 5.5).
Importantly, if providers fail to attest by the designated time, not only do they lose the meaningful use dollars, there will also be a negative adjustment to their Medicare/Medicaid fees.
Multiple studies have suggested the potential positive consequences of an EHR implementation. The Kaiser group reported that with an implementation of an EHR in the northwest United States, age-adjusted outpatient visits dropped by 9%, with only a slight increase in phone calls from patients but no change or a slight
improvement in quality metrics. Embi et al. found that by using EHR data to define patient eligibility into a clinical trial and then causing an electronic prompt to let the provider know of patient eligibility, they were able to double study enrollment as well as improve physician referrals to their study. In an obstetric EMR study, Klatt and Hopp demonstrated that through the use of best practice alerts in the EMR, they were able to significantly improve influenza documentation rates in pregnant women. The alert fired at each prenatal visit if the patient was either unvaccinated or didn't have documentation regarding refusal. Such alerts can be configured for a number of different clinical issues. However, a key to success is not creating “alert” fatigue and limiting the number of hard stops requiring active clinician input. The EMR is also only as good the data within it. We are aware that patients with gestational diabetes (GDM) are at increased risk for type 2 diabetes. Stuebe evaluated documentation of GDM in the EMR of a large health system. They found that only
45.8% of patients had the GDM history documented in the electronic problem list. This lack of documentation could lead to poor communication to the patient's primary care physician and the potential risk that the patient will not be screened when not pregnant.
FIGURE 5.5 Meaningful use incentive roadmap.
There are multiple factors that have made the adoption of the EHR difficult for some providers and groups. Likely highest among these is the cost to implement as well as maintain the EHR. Multiple third-party vendors exist that have various EHR platforms. These range from simple documentation and chart programs to software and hardware that integrate patient care across both inpatient and ambulatory platforms and the PHR. There are currently efforts to standardize EHR language, but many of these efforts are in their infancy. It will become critical as we evolve to an all digital-based health record that these systems are able to communicate with one another, allowing patients to have their records available anywhere and anytime. Ford et al. evaluated EHR adoption rates in small physician groups of 10 or fewer partners. Using models, they projected the potential for broad adoption of EHR into the future. They suggest that it may take until 2024 for small groups to fully implement EHRs, which is much longer than is currently being called for by agencies interested in quality initiatives and cost containment. Unfortunately, the health digital information superhighway continues to have a long way to go to be completed.
Baron et al. detail their personal experience as a small group of internists (four members) with implementing an EHR. They described alterations in work flow and the initial deterioration in their office environment for staff, patients, and physicians alike. However, they also state that in spite of the various limitations, “…none of us would go back to paper health records.” They identified five key issues that are likely relevant for both small and large groups involved with implementing an EHR:
1. Financing of the EHR
2. Interoperability, standardization, and connectivity 3. Work-flow redesign issues
4. Technical support
5. Issues of change management
More recently, there have been questions regarding whether the EHR is really the panacea for moving medicine to Six-Sigma quality. Computerized physician order entry (CPOE) has been suggested as a key element in
P.76 decreasing errors and improving quality. Several papers have recently addressed this issue with different
conclusions. Upperman et al. evaluated the rates of ADEs pre- and post-CPOE implementation. They noted an improvement in verbal order regulatory compliance, as well as an elimination of transcription errors after
implementation. They also noted a statistical decrease in harmful ADEs and suggested that this improvement would result in one less harmful ADE for every 64 patient days. Han et al. noted a different experience when implementing a CPOE system in an academic tertiary care children's hospital. Surprisingly, they noted that the mortality rate increased from 2.8% before CPOE implementation to 6.57% after, an increase that remained significant even after multivariate analysis. It is noteworthy that in this paper, the authors document that the CPOE training was given 3 months before implementation. They also note that the implementation itself occurred over a period of only 6 days for the entire pediatric hospital. This may be too long an interval from training and too short a period for implementation. It is interesting that two papers, both published from the same institution, could have such different conclusions.
Ash et al. have suggested that the mere implementation of an EHR is not in and of itself enough to insure that unexpected errors won't occur. They suggest that these errors fall into two broad categories: “those in the process of entering and retrieving information and those in the communication and coordination process that the patient care information system is supposed to support.” The key for powering the CPOE and the EHR is likely through well-thought-out algorithms that allow us to take advantage of the computer's ability to maintain data while attempting to best understand what a particular patient needs and while limiting changes in underlying clinical functionality, unless that change actually improves functionality.
There has also been a push to allow patients to have access to their records. This may enhance patient engagement and activation by facilitating the patients' ability to participate in their own care in a way not previously thought possible. Patients are able to view data within the EHR for accuracy, reviewing current or prior medications, allergies, etc. They could also be made aware of when lab test or studies are due or overdue, helping to improve compliance and screening. An even more novel concept that has been introduced by several groups is the ability of the patient to communicate with her
care providers through Web-based messaging. Initially, providers were concerned regarding the potential for overuse, but little evidence demonstrates this type of abuse. Indeed, in a time when it may be quite difficult to locate your patient during the course of a business day, dyssynchronous communication may be a preferable manner to communicate nonemergent information with patients. In addition, these data may be appropriately security encrypted at 128 bits and easily made part of the health record.
HIE are currently being pursued by a number of organizations and states. The hope would be true interconnectivity so that patient data could be viewed regardless of the point of presentation. Numerous technologic barriers exist to limit this functionality at present, but the hope of multidirectional data flow with immediate access to this vital information promises improved care for our patients.