David Nash, M.D., founding dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, Penn., is one of the nation's foremost experts on the task facing the healthcare industry as it moves to population health management models. He shared some of his insights with Health Data Management recently.
HDM: How should healthcare organizations prioritize facing the issues around EHRs with the issues around the other technologies that will facilitate population health management?
Nash: We want people to continue to focus on Meaningful Use. It's important and I'm not advocating abandoning it. But we are looking around the bend and thinking about where the buck is going, and we are confident it is all about measuring the outcomes of care from a population perspective. You cannot get that from an electronic medical record--that we view as an electronic chart and a charting system. The word we're looking for here is a registry function.
Here is my vision. I am a primary care general internist. One day on my office laptop I will be able to pull up all of my patients who have diabetes and all my patients in heart failure. And I'll be able to compare how I am doing across my small population relative to the population in our 20-person faculty group practice, and then I'll be able to compare our faculty group practice to regional and national benchmarks. So I will have, within moments, on my screen, a detailed view of how I am doing relative to the best available evidence. And the only way I can do that that I'm aware of is with a registry of some kind. Now, we know that all the major proprietors of these systems promote the fact they have a population health platform and, of course, the proof is in the pudding. The key issue is creating maintaining and using a registry.
HDM: The Buffalo-area Beacon project recently issued a report on how use of diabetes registries improved care at the community level.
Nash: There are pockets of progress here and there, for sure.
HDM: How do organizations have to prioritize their investments in EHRs and technologies such as remote devices that help make a registry architecture possible?
Nash: I think it's a parallel investment, and that's one of the many challenges we face. I can't tell institutions, "Well, hold off on your Cerner implementation so you can build a registry in the outpatient arena." Although people do view it as a tradeoff, we don't view it as an all-or-nothing phenomenon, one or the other. In fact we're quite emphatic it's a parallel structure. Because in the inpatient setting, there is no question we need the EHR for safety, for data collection, for Meaningful Use, for all those things. But in the ambulatory setting, to practice population-based medicine, you need the registry.
I get a call a week from some of these companies in the ambulatory setting, and they all have a population health platform. My first question is "Show me a mockup of your registry--and it better be primary care doctor-friendly, because we are the ones who will be populating it, and we will be the ones held economically at risk for it." So if you're going to put me in a pay-for-performance contract, give me the tools to proceed.
HDM: In the broader area of communications standards, organizations like the Internet Engineering Task Force usually operate under the idea of "rough consensus and running code" with little or no input from governments. How do you envision the standards process within healthcare evolving as the new data models emerge?
Nash: I am not a technology expert. Get me my registry. Here's the vision--the vision for when I finally retire will be seamless integration of inpatient and outpatient information on my web-enabled HIPAA-protected telephone at home on a weekend. You show me a place that can do that right now and I'll eat my hat. At my graduation from medical school in May 1981, the speaker from the National Library of Medicine said "one day soon" you'll be able to do what I just described. Well, I'm still waiting 33 years later. And, then the last issue. Let's just touch on the regional health information exchanges. Sounds great, I'm all for it--apple pie, motherhood, the Phillies in the World Series, but I'll believe it when I see it. And, I rank it far lower down in a priority list then the registry function.
HDM: In a recent talk, you mentioned that data from so many sources that are not healthcare providers will have to be pulled in to properly serve the population served by Medicaid ACOs.
Nash: That's the next stage. We are going to see the beginnings of promoting big data for population-based health analytics, and we recognize data systems concerning housing, poverty, smoking, and school attendance, just to name a few, all need to be connected.
HDM: What particular obstacles do you see looming in trying to engage the people who are contending with adverse environmental and social factors that aggravate their health status?
Nash: That's a huge issue. We have to align the economic incentives for the provider community, which will change behavior and enable us to align the data we'll need to practice population-based medicine. In other words, if you make it economically important enough for me to have all that data, I will find a way to do it and I'll convince my colleagues in various settings to support the work. If we are going to be rewarded based on accountability for a population, thats the key. With those resources, I can talk more carefully about community benefit and true measures about whether I am improving the health of the population or not.
HDM: In your experience, is the provider community aware of what they'll have to do in terms of forming these new partnerships and making them work?
Nash: No. I am on a National Quality Forum committee charged in part with organizing those measures of community engagement and it's an uphill battle. We're talking about measures of community engagement that will make your hair stand on end. For example, there are hospitals in the Midwest growing crops for poor patients--now, that's community engagement.
HDM: Do you think the expected fireworks over healthcare reform in the midterm election will affect the rollout of HIT deployment?
Nash: I dont see any impact from this election, no.
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