The Eyes Have It

No matter what technologies are used, the end goals for any organization are adoption and behavior change to achieve desired clinical and financial outcomes. Well-designed workflows that satisfy the needs of users lead to high levels of adoption of information systems. High levels of adoption that do not facilitate behavior change replicate systems and the undesirable outcomes achieved before technology deployment. Therefore, techniques that encourage behavior change, such as clinical decision support tools and performance scorecards, must also be embedded seamlessly in the clinical workflow to be effective.

Tools exist for achieving effective clinical workflow, although we continue to learn and refine best practices. Throughout the 1990s, payers employed clinician profiling reports or scorecards in an attempt to identify outlier providers and effect change in clinician practice patterns. Few of these efforts proved successful due to problems with data sources and the delivery and content of the scorecards.

With the expansion in the use of electronic medical records, the data source for scorecards that can influence clinician behavior moves to a much more robust data source, a data warehouse populated with clinical information gathered from multiple clinical systems. In addition, analytical tools now exist that can easily comb through enormous data sets and generate insightful results presented in attention grabbing, meaningful graphics.

Excerpts from: The Eyes Have It. PSQH, March/April 2013

Photo Courtesy of  Don Guerwitz Photography - At the Catania Market, Sicily, Italy

Next Generation CDSS: Patient-Centered Workflow

In the design of successful health IT implementations, patients matter. Although the importance of addressing the workflow needs of clinicians cannot be overstated, focusing on patient needs helps ensure newly designed workflows leverage the full capabilities of IT tools and embedded clinical decision support systems (CDSS).

In addition, this delivers the clinical and financial outcomes desired by organizations. Entities that ignore the needs of clinicians in designing health IT-driven workflows can expect to experience either low levels of health IT adoption among clinicians, suboptimal patient care results, or both.

Excerpts from: Next Generation CDSS: Patient-Centered Workflow. Health Technology Online, January/February 2013, p.10.

Photo Courtesy of  Don Guerwitz Photography – Guardians of the Gate. Angkor Thom, Siem Riep, Cambodia

We Know What to Do

Almost eight years ago Richard Hillestad and his colleagues from the Rand Corporation predicted that electronic medical record systems (EMRs) would generate cumulative efficiency and safety savings of $142 to $371 billion during a 15-year period, an average of $81 billion annually (Hillestad et al., 2005).

Just seven years later, Arthur Kellermann and Spencer Jones from Rand revisited Hillestad’s work and concluded that the increase use of health IT made the quality and efficiency of healthcare only marginally better. At the same time, yet, aggregate expenditures on health care in the United States have grown from approximately $2 trillion in 2005 to roughly $2.8 trillion today.

This Kellerman report evaluates four assumptions made in the original article by Hillestad and attributes the shortfall in observed versus projected results to shortcomings in four areas. Hillestad assumed the following in making his projections: 1) robust interoperability and interconnections of health IT systems, 2) wide adoption of health IT systems by clinicians, 3) effective use of health IT systems to impact care, and 4) changes in incentives and reimbursement systems that emphasized quality rather than revenue.

No surprises here. Anyone who toils in the health IT field knows that these four items represent the key challenges that we all work to overcome as we deploy our health IT applications. Counter to the pessimistic view that the billions of dollars spent on EMRs and other health IT systems are wasted resources, these investments offer a powerful force that, when the conditions are right, will significantly impact quality, safety, and cost.

Excerpts from: We Know What to Do. PSQH, January/February 2013

Photo Courtesy of  Don Guerwitz Photography – Temple Ruins. Sanka, Nam Belu River, Myanmar (Burma)

‘Show Me the Money’ Revisited

In the immortal words of Ronald Reagan, “There you go again.” Something that can be explained simply is twisted to look infinitely complicated with plots and subplots that would make J.K Rowling proud. The recent controversy over the use of EMRs to increase reimbursements to providers suggests intrigue, fraud, and bad intent. In contrast, if you learn how the money flows, you will better understand the true reasons for the outcomes seen in organizations using EMRs.

A New York Times report published in September 2012 documented an increase of $1 billion in Medicare reimbursements in 2010 over the amount paid five years earlier. The report partly attributed this payment increase to changes in billing codes assigned to patients in emergency rooms.

Such stories send shivers through the EMR community. To date, hospitals, EMR vendors, and the government struggle to demonstrate the value of EMRs in enhancing patient care and delivering cost savings. With billions of federal dollars earmarked to payment incentives for the use of EMRs, government officials anticipate some kind of return on this investment. Government EMR advocates did not expect to see an increase in reimbursements by public and private payors to providers through “enhanced” billing practices (code optimization [legal] or code maximization/up-coding [illegal]) activities.

Compared to paper records, EMRs allow for more rapid and complete documentation. In addition, EMRs slow the documentation process. Wait, how can EMRs both speed up and slow down documentation? It all depends upon deployment of the EMR and the constructed documentation workflows.

Unfortunately, EMRs focus on two important objectives at the same time– 1) facilitate clinical documentation to deliver patient care, and 2) facilitate clinical documentation to optimize coding for reimbursement. Documenting for patient care does not closely parallel documenting for reimbursement. As long as reimbursement is tied to documentation, EMR documentation workflow will suffer from inefficient documentation workflows, inaccurate documentation of care from global templates, and accidental (or deliberate) upcoding for reimbursement.

Excerpts from: ‘Show Me the Money’ Revisited. PSQH, November/December, 2012

Photo Courtesy of  Don Guerwitz Photography – Daybreak at the Ganges, Varanasi, India