Improving Care Coordination Through Health IT - Part II

Dr. Ann O'Malley and a research team from the Center for Studying Health System Change were profiled asking how care coordination could be improved through health IT. In Part II of this report, HTN sits down with Dr. O'Malley to ask about the study and its implications.

The study, published in The Journal of General Internal Medicine article, titled "Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices," interviews physicians and staff with at least two years of experience with commercial ambulatory EMRs in place, along with CMO's from Health IT vendors and national thought leaders on health IT.

HTN: Why is coordination of care so difficult?

Ann O'Malley: First, it is not compensated. So coordination activities carried out by clinicians and their staff are done at the expense of other billable activities. Next, the average Medicare beneficiary sees 7 different physicians in a given year, that's a lot of people with whom that person's regular doctor may need to communicate. Third, systems are not in place to facilitate communication among clinicians caring for the same patient.

HTN: What are the primary policy and technical changes that could help?

Ann O'Malley: First, the creation of incentives for providers to coordinate care and to communicate with one another would be helpful. This includes not just financial incentives, but breaking down some of the existing systematic barriers to coordination that are present in the fee-for-service system. Next, improving the basic care processes around coordination and the infrastructure to support those processes, such as improved health information technology capabilities important to coordination tasks, could be quite helpful.

HTN: You identified many opportunities to take advantage of current technology. Which of these were likely to have the biggest impact on care coordination?

Ann O'Malley: Interoperability between EMRs is key so that clinicians in different offices or across inpatient and outpatient settings can exchange patient data in a secure way that promotes coordination.

HTN: You also identified areas for EMR improvement. Which of these were likely to have the biggest impact on care coordination?

Ann O'Malley: It's hard to say at this point in HIT development. But among the clinicians we spoke with, the exchange of medication lists, problem lists, and communication around referrals and consultations as well as shared care plans were quite important.

HTN: ONC has published the rules by which eligible professionals will be receive incentive payments to be meaningful users of a certified EHR. Where are these rules on the mark, and where do they fall short in terms of facilitating coordination of care?

Ann O'Malley: They are appropriately taking an incremental approach because there is such variation in terms of EMR implementation among U.S. practitioners.

HTN: You interviewed clinicians and leaders that are working every day with EMR technology. What's their general "temperature" related to the state of Health IT and EMR's?

Ann O'Malley: In general, most clinicians would not go back to paper. They felt EMRs were an improvement for care provided within their office. For those outside of integrated delivery systems however, EMRS were not felt to be helpful as they currently are designed and used for coordination of care across offices or settings.
_____________________________

Ann S. O'Malley MD, MPH is a senior health researcher with the Center for Studying Health System Change. She conducts quantitative and qualitative research on a wide range of topics related to quality and access. She is particularly interested in primary care delivery, its intersection with specialty care, and the coordination of care from both the patient and provider perspectives. O'Malley completed her pediatrics internship at Georgetown University Medical Center and a residency in preventive medicine at the University of Maryland Medical Center. She received her master's degree in public health from Johns Hopkins and then completed a National Research Service Award fellowship in primary care research. She is board certified in preventive medicine and is a fellow of the American College of Preventive Medicine.

Improving Care Coordination Through Health IT - Part I

Coordination of care is a significant problem in part due to the large number of specialists involved in patients’ care and a perverse payment system that rewards the most expensive care, doesn’t reimburse for proactive health management, and drives fragmentation of care delivery.

Into this web, steps Dr. Ann O’Malley and a research team from the Center for Studying Health System Change (HSC), asking how care coordination can be improved through health IT. Their findings are published in The Journal of General Internal Medicine, “Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices”.  For their study, they interviewed physicians and staff with at least two years of experience with commercial ambulatory EMRs in place, along with CMO’s from Health IT vendors and national thought leaders on health IT.

'The study reports that a gap exists between policy makers' expectations that current commercial electronic medical records (EMRs) can improve coordination of patient care and clinicians' real-world experiences with EMRs.

Current commercial ambulatory care EMRs facilitate care coordination within a practice by making information available at the point of care but are less helpful for exchanging information across physician practices and care settings, according to the study supported by the Commonwealth Fund.

Clinicians identified many areas where both the design of EMRs might be altered, and office care processes modified, to improve EMRs' support for tasks involved in coordinating patient care.

Additionally, while current commercial EMR design is driven by clinical documentation needs, there is a heavy emphasis on documentation to support billing rather than patient and provider needs related to clinical management, the study found. And, current fee-for-service reimbursement encourages EMR use for documentation of billable events, office visits, procedures—and not for care coordination, which is not a billable activity.

"There's a real disconnect between policy makers' expectations that current commercial electronic medical records can improve care coordination and physicians' experiences with EMRs," said HSC Senior Researcher Ann S. O'Malley, M.D., M.P.H., coauthor of the study with HSC Senior Researcher Joy Grossman, Ph.D.; HSC Research Assistant Genna R. Cohen; former HSC Research Analyst Nicole M. Kemper, M.P.H., and HSC Senior Researcher Hoangmai H. Pham, M.D., M.P.H.

Excerpts from their findings that can be used to inform future EMR improvements include:

• EMRs may have unintended consequences for care coordination, such as creating information overload that complicates providers’ efforts to discern key clinical information. And, managing information overflow from EMRs is a challenge for clinicians.

• Clinicians believe current EMRs have limited ability to capture dynamic planning and the medical decision-making process in a way that supports future coordination needs—present EMRs focus on linear (moment-in-time) documentation while care coordination is dynamic and ongoing.

• Maximizing the potential of an EMR for coordination involves ongoing evolution of clinical care processes as well as clinician input on EMR design modifications and standards for data exchange to support those processes.

• Modifying reimbursement to encourage coordination of care by clinicians will likely drive clinicians to demand better EMR functioning to support coordination.

• Simply creating incentives to adopt EMRs as they currently exist, given the confines of the current payment system, may result in EMRs being designed for billing purposes primarily rather than for clinical relevance to patients and care coordination.'

The team identified EMR features that contribute to care coordination and areas for improvement.

In Part II of this article, HTN interviews principal investigator Ann O'Malley.

The Week in Review - May 7, 2009

AHRQ reports on "Innovations in Using Health IT for Chronic Disease Management" across a portfolio of health IT applications including clinical decision support, health information exchange, telehealth and hospital information systems. "We found no dominant technology application... The portfolio demonstrates that a variety of health IT applications have the potential to transform the quality and safety of care for some of the Nation’s most severely ill patients. Despite several challenges associated with developing and implementing health IT for chronic disease management, information technology can be used to improve clinical processes. Technology also can facilitate better knowledge sharing and support improved communication and coordination across care settings."

NCVHS hears from leaders on the definition of meaningful use including physicians, the Markle Foundation (and 60 supporting organizations), Agency for Healthcare Research and Quality (AHRQ), College of Healthcare Information Management Executives (CHIME), American Medical Informatics Association (AMIA), HIMSS and a broad range of other industry leaders. Carolyn Clancy, AHRQ Director, says that healthcare organizations should prepare now by using health registries to manage the health information of patients with chronic diseases.

Wall Street Journal reports on an "affordable fix for modernizing medical records", the VA's Vista system.

Dr. David Blumenthal, National Coordinator for Health IT, believes that healthcare technology has not advanced sufficiently "when left exclusively to the private sector, so there is a public role."

American Public Media's Markeplace reports that investment in "health care information technology is holding its own. Investors are following the $20 billion in President Obama's stimulus plan to upgrade and modernize health records."

The Use of Health IT in Crisis Control interviews Dr. Nathaniel Hupert, Director of The Preparedness Modeling Unit for The Centers for Disease Control and Prevention (CDC) and Associate Professor of public health and medicine at Weill Cornell Medical College.


Coordination of Care by Primary Care Practices: Strategies, Lessons and Implications reports that "while there was no single recipe for coordination ... some cross-cutting lessons were identified, such as the value of a commitment to interpersonal continuity of care as a foundation for coordination." Medical home initiatives "if aligned with payment incentives ... have the potential to increase quality and satisfaction among patients and providers by helping to move the health care delivery system toward better coordinated care."

Archives of Internal Medicine reports that "computerized medication reconciliation tool and process redesign were associated with a decrease in unintentional medication discrepancies with potential for patient harm. Software integration issues are likely important for successful implementation of computerized medication reconciliation tools."

Health Care Policy and Marketplace Review has maintained a laser focus on the need for healthcare reform to result in real savings. In his latest post, Bob Laszewski contends that "health care reform means fixing the system so we stop spending/wasting so much more than every other industrial nation on health care thereby making our system more affordable and effective." In earlier posts, he referenced two December 2008 CBO reports on the potential savings associated with various reform programs: Key Issues in Analyzing Major Health Insurance Proposals and Budget Options Volume 1 Health Care. "If the CBO just rolls over and lets Congress make up excuses just to spend more for health care we will not have reform--we will only have a bigger fiscal disaster on our hands. How do you reform entitlements by pretending?"

The AMA announces initial partner agreements to provide a secure AMA portal offering a variety of practice management services.

Computer modeling predicts the spread of swine flu. One of the algorithms is rooted in human contact models derived from Where's George? which tracks the passage of one dollar bills from person to person.

HealthMap provides a global disease alert map, including tracking of swine

How Hard Can It Be To Coordinate Care?

There's one patient, one primary care physician and a couple other providers, right?

Not from the perspective of the physician who has to coordinate with 229 providers across 114 practices. A recent article in the Annals of Internal Medicine spells out the challenge.

Dr. Mai Pham is the Senior Health Researcher and Co-Director for Quantitative Research at the Center for Studying Health System Change. She was the principal investigator for "Primary Care Physicians' Links to Other Physicians Through Medicare Patients: The Scope of Coordination of Care".

Mai recently sat down with Healthcare Technology News to talk about the study and its implications for healthcare reform.

HTN: Please tell us about the Center for Studying Health System Change. With all the work on health care reform, what will this next year bring?

Mai Pham: HSC is a non-partisan, health policy research organization in Washington that focuses on understanding how health policy decisions affect people and health care markets. The coming months obviously will generate a lot of debate on the issues we’re interested in. I think it will be interesting to see how policymakers balance the desire to broaden insurance coverage versus the need to rein in costs and at least begin to tackle re-design of the health care delivery system.

HTN: You just completed a study which found that the typical primary care doctor may need to coordinate care with 229 doctors across 117 different practices. That’s an eye-popping statistic.

Mai Pham: It really is very daunting. We worked hard to keep our estimates on the conservative side – we focused only on Medicare patients and only physicians. If you consider younger patients and important providers like nurse practitioners, those numbers would be even larger. We imagine that a primary care doctor wouldn’t necessarily be able to name all the other doctors in his or her “peer network.”

HTN: The reality is that doctors can’t stay meaningfully in touch with this many providers, right?

Mai Pham: It is possible that physicians manage to exchange some clinical information most of the time, with the peers that they know about. But it seems far less likely either (1) that they know who all their peers are since Medicare patients can self-refer to any physician and don’t necessarily tell their primary care doctor about all their other providers; or (2) that all these physician peers can really engage in meaningful, shared decision-making, which I think is one of the tougher tasks in coordinating care.

HTN: So what happens today? And what should be happening?

Mai Pham: My guess about what’s happening today is that both patients and physicians feel overwhelmed by the fragmented nature of care and care relationships. Often it will seem to them that it’s not possible for anyone to really steer the ship in a way that is consistent with a patient’s needs and preferences. I think a more ideal situation might be one in which a patient identifies a single practice as their “medical home,” and is honest with that practice about care that they seek elsewhere. Then the medical home would have a reciprocal responsibility to choose their peers carefully based on those peers’ demonstrated willingness to communicate and coordinate with them, explain to patients why they prefer some peers to others, and not least – get paid to do that coordination work, which they don’t have under fee-for-service structures.

HTN: Since your study was limited to fee-for-service Medicare patients and didn’t consider non-physician providers, it’s likely that the actual number of provider links is greater than the median 229. Care to guess how much greater?

Mai Pham: I don’t think it would be as large as double, because Medicare patients will tend to be sicker and require more different physicians than will other patients, but I think it would be noticeably larger, especially for family practitioners who also need pediatric consultants. Let’s just say I pale at the thought….

HTN: You suggest that this fragmentation of care might be effectively addressed by formalizing relationships and tying payment to “peer webs”. Can you explain the peer web concept?

Mai Pham: Other terms that try to capture the same concept include “medical neighborhood” and “peer networks.” The concept is that no physician has sole influence over their patients’ care. Even if I am the main provider for my patient, their “medical home” if you will, I need to coordinate shared decision-making with all the other providers who also treat my patient. If you extend that one “web” for one patient to all of my core patients, you start to see the complexity of my total “peer web.” It’s really about shouldering the burden of care coordination as a primary care doctor.

HTN: You found that patients are seeing “7 different physicians from 4 different practices in a given year, and care of patients with multiple chronic illnesses is even more fragmented.” What does this fragmentation of care mean to the patient? Will peer webs help?

Mai Pham: For patients, I think it means a lot of mental energy goes into navigating the system, having potentially redundant conversations with different physicians, and in the end, not necessarily getting the care you need or want because details fall through the cracks. I think rationalizing peer webs can help, if there is an explicit understanding between different physicians and between physicians and patients that “this is what you can expect of me when you send me a referral” or “this is what we will do together when we consult you.”

HTN: What are the implications of your study on the requirements for the Advanced Medical Home?

Mai Pham: I think there is interest in broadening the medical home concept to incorporate this notion of a “medical neighborhood” in a way that sets realistic expectations for how physicians outside of the medical home will behave, and how each physician will be paid to support shared decision-making and effective coordination.

HTN: What other implications does your study have for the health care reform debate now underway?

Mai Pham: I think it is very tempting for reformers to focus on creating “winners,” for example by offering greater access to insurance coverage. The flip side of that is ensuring that once someone has insurance, they can actually get good care. Whether or not they take it as one of the early steps in reform, policymakers will eventually have to confront the need to re-design the care delivery system, or the money we spend on increasing access may not be worth it.