The conference feels like it’s overflowing (there are 30,000+ attendees, a record turnout), and most educational sessions are pretty well packed, in stark contrast to some past shows where there’s a handful of sleepy attendees and an endless PowerPoint flipping across a projection screen.
While there are a lot of sessions with “Meaningful Use” or “Stage 2” in the title, most sessions have been circling back by various paths to health information exchange because of the requirements for care continuum/coordination sure to be baked into Stage 2 meaningful use criteria.
What’s really eye-opening is just how far the industry is from being able to truly coordinate care. Tom Yackel, M.D., the CMIO at Oregon Health & Sciences University, gave a presentation about how the health system is preparing for care coordination requirements, and peeling back the layers of this onion is a frightening exercise.
He gave an example of a 75-year-old woman, with diabetes, systolic hypertension and a couple other co-morbidities thrown in, and charted how her care history would flow … a primary care doc, a dozen or so specialists, a dozen or so medications …. an example completely rooted in reality.
Yackel went on to show how medication reconciliation is an exercise in futility for this common patient population, and then cited some troubling research: the majority of times, a primary care physician doesn’t know his/her patient has been hospitalized until they get a handwritten discharge summary (if they in fact receive it at all). And patients themselves can’t provide much insight, since another study shows only about 50 percent of them understand the various care plans put in their hands, or can understand what’s communicated by them.
Note that while Stage 1 meaningful use criteria had a few passing mentions of care coordination, Stage 2 likely will have very granular and specific measures. What’s been proposed to date will include:
* Measures assessing adherence to a comprehensive care plan in the EHR with an up-to-date problem list and care plan that reflects goals of care.
* Measures of an Advance Care Plan as a product of shared decision making.
*Measures of the success of a sel- management plan for patients with conditions where a self-management plan might reasonably be considered to benefit them.
*Measures of reconciliation of all medications when receiving a patient from a different provider.
*Measures of patient and family experience of care coordination across a care transition.
* Composite measures assessing receipt by both the care team members and the patient/caregiver of a comprehensive clinical summary after any care transition.
*Measures assessing timeliness of provider response, and appropriate response, to clinical information, including lab and diagnostic results.
Oregon Health & Sciences, for its part, has piloted a program focused on using care managers and a big heap of I.T. to coordinate the current mess. There are more details about the Care Management Plus Program (which Oregon cribbed from Intermountain Healthcare, available here) http://caremanagementplus.org/about.html. Yackel’s session slides are available here.
Health information exchange seems to be a pretty daunting task, care coordination on another plane entirely. But what’s news is how aggressively even the tiniest of organizations are going after EHRs and setting up HIEs. Mark Anderson, the CEO of 20-hospital Doctors Diagnostic Hospital, about 45 miles north of Houston, has managed to set up an HIE anchored by an EHR at Doctors Diagnostic, and he’s done it on a shoestring. He’s got 85 doctors in 61 practices roped in, and the secret sauce was the requirement that they standardize on the HITSP/C32 Version 2.5 CCD standard of the Continuity of Care Document.
After he got all the practices standardized on that version, he then got local payers, Quest Diagnostics, SureScripts and Lab Corp., among others, to backload the HIE’s repository with visit data, patient demographics, labs, prescription data, etc.
Anderson said he got the HIE operating with $25,000 in interface work and monthly fees for specialists to access the data. He’s done a number of time and motion studies and found, among other benefits, that unnecessary tests have been reduced by 73 percent, the amount of paper handled between the hospitals and physician offices has been reduced by more than 80 percent, and medical errors have been reduced by 78 percent.
His slide show is here and contains some interesting nuggets about why some physicians have cultivated a hatred of EHRs, and the sound reasoning behind that animosity. For example, research by the AC Group found that it takes physicians nine times longer to document with EHRs than with paper; EHRs may contain more than 700 data elements, but only 3 percent those are actually used by physicians; electronic clinical notes are readable, certainly, but the length of an average clinical note has expanded to five pages from one page.
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