Quality improvement initiatives in provider organizations often go bad when they are mandated from the top down, and not integrated into clinical workflow and compete with other priorities, asserts Chris Wood, M.D., a family physician and medical director for information services at Intermountain Healthcare in Salt Lake City.

That’s why Wood worries that the HITECH Act’s incentive payments for meaningful EHR use will result in providers documenting meaningful use, but not really becoming meaningful users. For instance, one meaningful use criteria requires 80 percent of patients to have at least one problem on their problem list. Intermountain, which started building its EHR in 1968, currently has 1.7 million patients in its records database, with 58 percent having at least one problem on their list.

Wood wasn’t thrilled with some colleagues’ suggestions on how to get to the 80 percent threshold--document that 22 percent don’t have a medical problem or mandate physicians to put a problem on the list. But is that really meaningful use? Wood doesn’t think so.

The answer, he says, is to use the capabilities of information systems and the data within them to build problem lists into clinician workflow and associate a problem with appropriate billing data, such as the CPT code. “Automation must improve productivity without damaging clinical workflow,” he said at the Institute for Health Technology Transformation’s Summer Health IT Summit in Denver.

Having some component of an EHR for four decades, Intermountain has a formidable data warehouse supporting its 23 hospitals and more than 140 clinics. Using that data has helped the organization implement “bottom up” quality initiatives created within the organization with hard numbers that show whether the initiative are working, Wood says.

For instance, a survey of Intermountain physicians in 1985 found 100 percent said antibiotics to prevent post-surgical infection were given at the right time, but data showed only 40 percent compliance. Knowing that, the hospital was able to raise the rate to 58 percent one year later and 96 percent by 1991.

In another example, Intermountain went against conventional wisdom and waited until the 39th week of gestation for elective pregnancy inducements. The result, because the cervix was more ready for delivery and the baby spent more time in the womb, was significantly fewer Cesarean sections and admissions into the neonatal intensive care unit. Billings for these services went down, but costs went down more.

So, to get real meaningful use out of an EHR, Wood advises selecting a system with customizable documentation tools and granular data capture capability, establishing a data warehouse, and creating clinical teams to work on specific high-risk initiatives. “Start planning now on how to get the juice from your investment in HITECH.”

--Joseph Goedert 

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