BACKGROUND
US Healthcare System
Problems
1) Inefficient
2) Ineffective
3) Unsafe (medical errors)
4) Unequal access
Root causes
1) Complexity of the system
- multiple independent agents
- each acting in their own self interest
- adapt to maximize their preceived interest
- no entity is ultimately in charge (fed does not have the capacity to play that role)
2) Perverse incentives that drive processes rather than results
3) Structural problems - system is aligned with managing acute conditions rather than chronic cases, which are more common and growing
4) Technology limitations in the lack of deployment of technology
Health Information Systems
Health workers collect data, act on that data, follow what happens, and adjust accordingly. Historically done on paper, which is prone to error.
Issues:
- Health workers work mostly in silos without much interaction between different practices or providers
- Patients receive episodic care, i.e. interaction between providers and patients is limited to only during visits
The HIT Solution
- The HIT (i.e. Health Information Technology) Solution seeks to address this coordination and integrated information access challenge. The following diagram illustrates the HIT Solution contains smaller systems that build into a more comprehensive information access platform.
- Electronic Medical Records (EMR)
- Types of EMR
- Hospital (enterprise EMR)
- Has many departments such as Pharmacy, Lab, etc.
- Each department has its own EMR
- Those are brought together with enterprise view
- Mostly client-server system, now some cloud-based
- Provider (Office-based EMR)
- Simple system
- Adoption is a challenge
- Elements of an EMR
- Patient demographics
- History, physical examination and progress notes
- Allergies
- Immunization status
- Laboratory and other test results
- Imaging studies
- Medications
- Functionality of an EMR
- Track individual patients care over time
- Trend key measures such as blood pressure
- Identify patients due for visits or procedures
- Remote data access for the provider
- Monitor quality of care within the practice
- EMR v EHR
- EMR: digital version of the paper charts in the provider's office
- Chart is no longer passive - it is used to improve quality of care
- Reminders
- Practice guidelines
- Clinical decision support
- EHR: the total health of the patient - all providers, data from the patient and other sources
- single unified view of that patient
- Coordinate care among practices
- Manage care quality across practices
- Patient retrieval and recording of health data
- Patient (PHR - Personal HR)
- For patients to manage their own data; through apps, etc.
- Health Information Exchange (HIE)
- secure transport of protected data
- cloud-based
- Care coordination systems
- New concept
- Coordinate care across regions
- Most are cloud-based
- Identify patients outside of care standards
- Identify practice variations
- Manage provider performance
- Outcome reporting
- Resource management
- Public health surveillance database
- Public Health reporting of key data for surveillance
- Ex: CDC's flu tracking using EMRs across the country
New Care Models
- Patient Centered Medical Home
- Core features
- Personal physician
- Provides first-contact, continuous, and comprehensive care
- Physician-led team
- multidisciplinary team of individuals who care for patients
- Whole-person orientation
- care for all stages of life
- acute care
- chronic care
- preventative services
- end-of-life care
- Coordinated care
- Facilitated by registries, IT, HIE, and culturally and linguistically appropriate services
- Quality and safety -
- physician-patient partnerships,
- evidence-based medicine
- quality improvement
- patient participation in care
- practice participation in voluntary recognition process
- Alternative scheduling arrangements - various methods for communication between patients and their physician or care team
- Payment reform - alignment of incentives to support coordination of care
Policy and Initiatives
IT Policy Overview
- 1912 Teddy Roosevelt -->
- After WWII Truman -->
- 1971 Nixon put together an ambitious agenda:
- Assuring equal access
- Balancing supply and demand (grow the system)
- Organizing for efficiency
- 1984 Clinton reintroduced the notion of Health Care Reform --> nothing happened
- 2005 Bush W proposed universal computerizing health records to avoid dangerous medical mistakes; started a coordination committee --> nothing happened
- 2008/2009 Low adoption: 1.5% US hospitals, 4% physicians
- 2009 ARRA (HIT)
- Obama took stimulus bill to push for HIT adoption
- 2010 Health Reform (incentive reform)
- A major attempt to change incentives
- Universal adoption of HIT by 2014
- New outcome-based incentives proposed by Dartmouth
HIT Adoption:
EHR Certification --> Meaningful Use --> Medicare/Medicaid Incentive Payments
- provider can make profit from adopting the system by properly selecting their systems