By Scott Thompson, RN
CIO / Tech Strategist
With the constitutionality of the Affordable Care Act under debate for the past three years, we continue to see our leaders in Washington and across our nation contend that Electronic Medical Records (EMRs) will improve patient care, decrease provider mistakes, increase provider availability, and reduce the cost of Medicare & Medicaid programs. In my experience over the past few decades, even with impressive improvements in EMRs, HIEs, Provider Office systems, hospital and health plan systems, a huge gap remains between our current EMR/HIE patient systems, and what is needed to truly “represent” our patients lives. EMRs are, in effect, hiding our members behind mountains of data.
Our new EMR/PHR/HIE systems, with discrete data points gleaned from dozens of sources presented on our screens in tables, graphs, reminders, and notes, may actually distract our care providers from “seeing” patients in ways that truly help us address the issues, including those targeted by Washington in programs like the ACA.
It’s easy to confuse lots and lots and lots of data being generated, shared, stored, averaged, trended and predicted, with having useful knowledge we can act on to positively impact patients’ lives. This is especially true in health care since it’s seldom that any one data element such as weight, blood pressure, HgA1c level, or coded diagnosis, has significant meaning on its own. What we’ve found instead is that, generally, it’s not until these items are viewed together (i.e. it’s determined the patient is an overweight, hypertensive diabetic with an HgA1c level of 10), that we fully realize the chronic, severe, and costly situation both the providers and the patient face.
Every day, systems gather hundreds or thousands of these measurements for every patient. Twenty years ago, physicians, nurses and aids created written flowcharts to track patient progress and to provide the baseline data required for clinical decision. Today’s EMRs and HIEs have certainly improved access to data, but they have not substantially changed our view. With thousands of data points, are we really seeing our members and patients as individuals, or just as an aggregate of data analytics?
Don’t get me wrong: all that data, and the clinical pictures it presents, are important and can have a very real impact on health care delivery, accuracy, and cost, especially in Acute Care settings. But our biggest problems today are no longer Acute, but instead mostly Chronic. We have done a great job with infection, trauma, and heart attacks, but continue to struggle with parallel conditions such as Diabetes, Hypertension, COPD, Renal Disease, Cancer, and Atherosclerosis; Chronic diseases that require long-term, life changing solutions if we are going to have a net-positive impact on them.
Our systems need to do a better job telling us about our patients’ daily activities, providing insight into repetitive, negative or self-destructive habits. And, we need to make this information available in a thoughtful way to our health care providers if we really want to help our patients understand and implement changes that will help them to live better, for longer, and, at a lower cost. To do this we need to move beyond the basic physician/provider encounter with the patient.
The standard 14.5 minute basic office visit is marginally sufficient for managing a single acute issue, ordering some labs, and adjusting some medications. (Although many would argue that the basic visit is already insufficient for doing even this much.) To make better use of that time, providers are now turning to their allied staff—PAs, RNs, assistants, and the front office—to help them collect and confirm patient information ahead of time and, to complete interventions and paperwork following a patient visit.
Why don’t we widen the circle a bit and use our technology to bring in additional staff to make this encounter even more productive? The whole point of EMRs, PHRs and HIEs is to broaden the reach of health care providers (in the most generic sense), and to remove the constraints of physical proximity to information sharing. Providers should expect the same level of interaction and communication with Chronic and Home Health care staff (wound care, diabetic management, infusion therapy and case management providers) that they have with the medical assistant who, prior to an exam, records the patient’s vital signs. By doing so, the Provider would not only order the care, but participate in the implementation. The result: the Provider’s meeting with the patient would reinforce established goals and interventions.
Some say we are doing this now, pointing to the dozens of notes and reports that, between visits to the provider, have been added to patient charts. But many of these reports and notes are too wordy and require too much time to read, making it near impossible to extract the salient points that might benefit the provider-patient encounter.
Instead, and if we truly desire to have the patient/provider EMR record to properly reflect problems, goals, tasks, and interventions, we need to engage the participation of extended chronic care and home care providers. For example, in this model of care, a wound assessment would be delivered to the provider alongside the patient’s vital signs as part of the EMR record problems, observations and ordered care. Since the delivery of that information would come in the format and context of the EMR (and perfectly aligned with any existing provider/patient visit protocols) providers, patients and chronic care providers would all experience greater efficiencies. This benefits all, since enhancing the provider patient encounter would also reduce the provider’s in-office associate and staff workloads.
If we truly desire to improve patient care, decrease provider mistakes, increase provider availability, and reduce the cost of Medicare & Medicaid programs, we need to look beyond EMR systems alone. Yes, we need timely and accurate clinical data. But it’s not enough. Patient-centric ongoing care requires more than the “old” acute care visit model. Unless we begin building ‘bridges’ to span the mountains of data being collected, I fear that both patients and providers will remain isolated on islands of information, invisible to one another because of their inability to interact and communicate.