Understanding Patient Centered Medical Homes and Accountable Care Organizations: Part 1 of 2

I’ve been blogging about patient centered medical homes (PCMHs) for the past five years and accountable care organizations (ACOs) for the past two years. In this post, I discuss how these healthcare delivery models are similar and where there are significant differences. In a follow-up post, I will explain why we need both.

According to the American College of Physicians, a PCMH is:

...a model of care that puts the needs of the patient first. The medical home is the base from which health care services are coordinated to provide the most effective and efficient care to the patient. This includes the use of health information technology, the coordination of specialty and inpatient care, providing preventive services through health promotion, disease management and prevention, health maintenance, behavioral health services, patient education, and diagnosis and treatment of acute and chronic illnesses...Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. The medical home is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. The personal physician leads a team of individuals who collectively take responsibility for the ongoing care of patients...Quality and safety are the hallmarks of the medical home. Evidence based medicine, health information technology, and clinical decision support tools guide decision making to support patient care, performance measurement, patient education, [whole person orientation] and enhanced communication. Ensuring the coordination and comprehensive approach of the medical home model over time will improve the efficiency and effectiveness of the health care system and ultimately improve health outcomes (Reference).

The ACO model, on the other hand, is loosely define and has different sub-models. According to a recent article in ModernHealth titled “Forging the way: ACOs taking hold despite loose definitions,” an ACO is:

...a fashionable name for a loosely defined fix for U.S. healthcare, are the center of debate, gossip and conjecture among policymakers and the healthcare leaders. But the murky state of the model and poorly received draft regulations intended to clarify the sketch included in the healthcare reform law have not deterred plans among some hospitals, medical groups and payers to…reduce medical errors and waste with financial incentives for quality and lower costs…[by] more closely coordinat[ing] medical care. Markets with competitive or highly independent providers would likely need more time and options to develop accountable care than large health systems with an existing network of employed physicians…Providers who agree to join these endeavors are vulnerable to costly missteps that could put finances and patients at risk…Success will depend on several factors…including hefty financial incentives tied to quality measures and freedom for patients to choose providers (Reference).

ACOs can also be described as:

…vertically integrated organizations of care, which are at minimum composed of primary care physicians [PCPs], a hospital, and specialists…The intent is to coordinate care under the auspices of one organization…[and] providers are held directly responsible for the health of their patients and are evaluated based on their effectiveness, efficiency and quality of care in treating patients. [P]rovider members of ACOs work together across all of the specialties to develop care delivery programs which focus on outcomes and coordinating care…ACOs encourage physicians and hospitals to integrate care by holding them responsible for quality and cost (Reference).

Similarities between a PCMH and ACO

Based on these definitions, PCMH and ACO models both attempt to increase healthcare quality and reduce costs (i.e., deliver high value products and services) by (a) coordinating care, (b) being accountable for the care’s quality and efficient delivery, (c) having a strong primary care core, and (d) consolidating multiple levels of patient care.

According to a recent NY Times Op-Ed piece titled “Cut Medicare, Help Patients,”professors Emanuel and Liebman explain how PCMHs and ACOs provide “seeds of a solution” to controlling Medicare spending by enabling the country to take “a path to smart cuts” by focusing on the:

…need to stop paying for wasteful procedures…and empower doctors, nurses and hospitals to provide higher-quality and more efficient care… these reforms allow [bundled] payments…based primarily on the number of patients cared for and the quality of that care rather than on the volume of services provided [and can] eliminate spending on medical tests, treatments and procedures that don’t work — or that cost significantly more than other treatments while delivering no better health outcomes. And they can be made without shortchanging patients…Smart cuts can also be achieved through better coordination of patient care.

These smart cuts would be an antidote to the “…ill-conceived cuts that…got serious consideration in the recent debt limit negotiations.” These ill-conceived cuts include: (a) Meat-cleaver cuts hack spending indiscriminately…across-the-board”; (b) “Cost-shifting cuts don’t actually reduce health care spending; they just shift costs from the government to the private sector;” and (c) “Penny-wise, pound-foolish cuts reduce current spending by a little but raise future costs by a lot. Raising co-payments for office visits and medications is a good example. Both PCMHs and ACOs would receive financial incentives for controlling care costs and improving quality:

• "The incentives of the ACO are clearly different from the current fee-for-service reimbursement system. The focus of the ACO is to streamline its processes and care while exceeding the norm on quality and outcomes. If the organization spends less than projected, all members of the ACO share in the bonus payments thereby incentivizing effectiveness and efficiency. If, on the other hand, an ACO underestimates the cost of operation, the providers will earn less, thereby institutionalizing ‘accountability.’” (Reference).
• Different financial incentive models for PCMHs are just beginning to emerge. There are a few pilot projects of financial incentives for PCMHs. For example, (a) Health Plan of Michigan has announced an incentive program that encourages providers to become PCMHs by providing financial assistance during the practice certification phase (Reference; (b) six health plans in New York are paying $1.5M in incentives to create medical homes (Reference); and (c) the multi-state Safety Net Medical Home Initiative (Reference).

 PCMH and ACO Differences

While PCPs are core to the care delivery process in both models, a single independent PCP practice heads a PCMH; this is unlike an ACO in which many coordinated PCP practices working together headed a single organization that is typically a hospital or health plan. That means a PCMH is accountable for care cost and quality rendered by one PCP and the specialists treating a particular patient. In contrast, an ACO is accountable for care delivered across multiple PCPs, specialists and hospitals.

Other differences include the following ...

In an ACO, providers form a “tightly-coupled” network in which everyone operates under the same “global standards” by using the same preferred practice guidelines, health IT and centralized communications. This can:

• Streamline central management and control of patient information
• Promote “top-down” (hierarchical) decision making in which “weak voices” (i.e., people not high in the hierarchy) do not have much influence in how things are to be done
• Reduce clinician autonomy and empowerment.

In contrast, each PCMH is a “loosely-coupled” network of PCPs and specialists with its own “local standards” for clinical processes, health IT and point-to-point (decentralized) communications. This can:

• Provide personal management and control of patient information “owned” by each clinician
• Promote collaborative “bottom-up” decision making in which all involved clinicians have a meaningful say in how things are to be done
• Increase clinician autonomy and empowerment.

In my next post, I’ll discuss why both PCMHs and ACOs have an important role to play, as well as how they can operate within a health information exchange (HIE) to emerge clinical knowledge that is useful to everyone.

Webinar: Live Demonstration of our Medical Home Health IT Invention

Join us for a Webinar on August 10   

An idea conceived 30 years ago—for a simple, secure, low-cost way for people everywhere to collect, exchange and use relevant health information—is now a reality.

During this webinar, we will demonstrate and discuss how the ReAsure HealthNode™ (RAHN™) MedHome software offering enables the right people to share the right information at the right time, and to do it securely and for the right price. RAHN™ uses four beneficial methods to achieve this:

1. It obtains, combines and analyzes all types of health data from any sources with a powerful electronic processing engine
2. It protects the health data under lock and key with a state-of-the-art electronic file cabinet
3. It turns the health data into useful information with an ingenious electronic document designer
4. It sends the information through the Internet quickly and easily by secure electronic mail.

From a technical perspective, these software programs provide a desktop-to-desktop solution that bridges the HL7/middleware interoperability requirement to provide HIE-to-HIE interoperability in a fragmented clinical information exchange environment. They can work with any databases and data formats.

From a clinical perspective, our easy-to-use programs add translation and collaboration capabilities to help simplify a provider’s workflows and support clinical decision-making.

The webinar will focus on one of the RAHN™ MedHome programs, the Referral Manager application, which is currently in pre-production testing. This flagship software program enables primary care providers (family physicians, GPs, etc.) to manage referrals and coordinate care in patient-centered medical homes and other care settings.

It costs only $49.95, and you can download and install it yourself. There’s truly nothing like it! Come see for yourself.

Clinicians, researchers and health IT developers are welcome. We are very open to collaboration.

Title: Live Demonstration and Discussion of the ReAsure HealthNode MedHome Software Offering
  
Date: Wednesday, August 10, 2011
  
Time: 2:00 PM - 3:00 PM EDT   

Space is limited.
Reserve your Webinar Seat Now at:
https://www2.gotomeeting.com/register/865628378

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System Requirements

PC-based attendees
Required: Windows® 7, Vista, XP or 2003 Server

Macintosh®-based attendees
Required: Mac OS® X 10.5 or newer

Is the Annual Wellness Visit Program a Farce?

Jane M. Orient, M.D.—Executive Director of the Association of American Physicians and Surgeons—recently sent an e-mail titled “The Medicare ‘Wellness Farce’ that ridicules the value of Medicare’s annual wellness visit (AWV) program. This is a healthcare reform program of the Federal government’s Affordable Care Act, which is meant to cut healthcare costs by promoting good health. While she believes it is likely to control spending somwhat, she conjectures that the “well care” is not a good thing for people who are ill because it will take money away from their “sick care” they need. Here closing sarcastic statement was: “It is much better for society to keep healthy people healthy than to lavish resources on keeping sick people alive. Isn’t it?

My response to that last comment is this: Keeping healthy people healthy AND keeping sick people alive are BOTH good for society. However, lavishing resources on keeping sick people alive insinuates uncontrolled spending since the word lavishing could mean extravagance and excessiveness.

A much better statement, therefore, would be: It is equally important to society to keep healthy people healthy as long as possible, as well as helping sick people manage or overcome their health problems, while wisely/prudently/judiciously distributing our limited resources. This statement implies the need to focus on two things largely absent from in our current healthcare system

1. It is crucial that the patient/consumer gets true value for the care received. That is, care cost-effectiveness must be the primary factor in determining how to spend our healthcare dollars.

2. A whole-person integrated care approach is the most rational way to go. This model does two things: It (i) brings together well-care and sick-care and (ii) focuses on improving a person's health and wellbeing by addressing one's physical health (body), mental/psychological health (mind), and the mind-body connection ("holistic" health). In other words, it views an individual as a whole entity, whose body, emotions, thoughts (e.g., attitudes and expectations) and behaviors are interconnected. See this link for more: http://curinghealthcare.blogspot.com/2008/02/patient-centered-life-cycle-value-chain.html

Are Healthcare Services and Products Merely Commodities?

I had a discussion with someone who brought up an interesting point about insurers/payers who treat healthcare services (tests and procedures) products (medications, lab work, medical devices, etc.) to be commodities that are by paid piecework. This model is in sharp contrast to the Pay-for-Value/Value-Pricing model I've been proposing.

The idea that healthcare services and products as commodities is based on faulty reasoning. In reality, the services rendered by different providers, and the products produced by different manufacturers, are often not equally (a) effective in terms of safety and quality (degree of risk and benefit to the patient); (b) efficient in terms of speed and resource consumption; and (c) affordable in terms of overall cost. In other words, they are not equally cost-effective. As such, it is irrational to pay the same amount across the board for a particular type of healthcare service and product. A more sane approach would be to use a value-based model of pricing that pays more for the services and products that deliver greater value to the patient/consumer by being more cost-effective.

There are many reasons why American healthcare does not have such a value-based model. An excellent article recently published in NEJM (at this link) addresses this issue directly: The $640 Billion Question—Why Does Cost-Effective Care Diffuse So Slowly? Bottom line: There is little financial incentive, and great disincentive, to promoting cost-effectiveness in the current US healthcare system. Here’s a brief quote:

“To avoid financial crises in federal and state governments and turmoil for health care stakeholders, U.S. health care must become more cost-effective. The United States spends much more per capita on health care than do other developed countries, with broad outcomes no better than those of its peers...There are, however, individual U.S. physicians and health care organizations that deliver high-quality care at a cost roughly 20% lower than the average. If the rest of the U.S. health care industry followed their example…$640 billion would [be saved. The reasons for our failure to focus on cost-effectiveness] lie in the perceptions and behaviors of the major participants in health care.”

I’ve been writing about the need for a value-based healthcare system since 2007 (see http://curinghealthcare.blogspot.com/2007/10/path-to-profound-healthcare.html and http://curinghealthcare.blogspot.com/2010/08/healthcare-reform-models-focusing-on.html). It seems to me that fixing healthcare in the US (and our economy in general), requires (in part) that we transform our pathologically mutated model of capitalism (see http://curinghealthcare.blogspot.com/2008/02/us-healthcares-perverse-commercial.html) into a rational model based on rewarding delivery of value to the consumer!

Personal Health Information Security

We’ve been having an interesting technical discussion at LinkedIn (at this link) about health information security when trying to share patient data among multiple data silos. We’re examining issues concerning the security of cloud computing, e-mail, and information stored in local computers and mobile devices. We’re discussing the strengths and weakness of encryption, exploring reports of data breaches, and identifying the incremental risks of different security prevention approaches.

We’re also presenting and evaluating innovative security solutions, such as: (a) allocating a specific IPv6 block just to healthcare; (b) using a novel method that is impossible hack (even with brute force) by “scrambling and padding” patient data using multiple keys; (c) separating patient identifiers from the person’s clinical data; and (d) using globally unique IDs (GUIDs) to name patient data files and mapping the GUIDs to the actual patient identifiers.

These kinds of creative discussions and brainstorming are essential when seeking solutions to the daunting challenges facing healthcare reform. The important thing, imo, is to be open to all ideas and critically examine them in terms of strengths, weakness, problems and risks.

Related posts:

• Should Personal Health Information Reside in Silos?
• Who should Own a Patient’s Health Data, Where should they be Stored, and How should they be Exchanged (Part 2 of 2)
• Personal Health Information Privacy

Healthcare Reform "Value Promotion & Reward" Strategy

I've been writing about the need for high value healthcare for over four years. In the past year or so, more and more people have begun discussing the notion of value with regards to healthcare reform.

I've recently participated in one such discussion at KevinMD in a post about the tension between physicians and health policy experts (at this link) and another about how physician consolidation places health reformers in an ironic dilemma (at this link).

My comments focused on making the case that success healthcare reform models must be built on strategies focusing on (a) delivering high value care to every patient (client/consumer) by (b) enabling and rewarding the efficient delivery of high quality (safe & effective) “sick-care” (treating illness and dysfunction) and “well-care” (prevention and self-maintenance) within (c) a trust-worthy learning environment that promotes continuous, demonstrable improvement in care value.

Such strategies measure value as quality divided by cost, which is a measure of cost-effectiveness.

Key tactics of this value promotion & reward strategy are:

• “Value-pricing,” which means paying more for healthcare services and products proven to be more cost-effective (and vice versa)
• Patient-centered cognitive support, which consists of advanced health IT systems that help practitioners/clinicians/providers avoid information overload as they: (a) gain deep knowledge patients’ problems and risks, along with sharp awareness of the most cost-effective diagnostic, treatment and prevention options and (b) use that knowledge and awareness to make valid decisions, take competent actions and achieve good outcomes 
• Shared decision-making, during which health practitioners educate patients about their treatment options in understandable language that takes into account patients’ individualized needs, circumstances and preferences
• Practice-research collaboration (knowledge networks) that generate and disseminate ever-evolving evidence-based preferred practice guidelines and self-help recommendations
• Healthcare delivery models assuring access and availability of high-value care to everyone.

Related posts:

The Need for a Value-Pricing Model in Healthcare
Enabling EHRs to Improve Care
Healthcare Reform Models Focusing on Value to Consumers - Part 1
Healthcare Reform Models Focusing on Value to Consumers – Part 2
Healthcare Reform Models Focusing on Value to Consumers – Part 3
Four Interlocking Issues about Fixing American Healthcare
Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Pay for Value

The Need for a Value-Pricing Model in Healthcare

We must reduce overall healthcare costs and improve quality, which would increase value to consumers (patients/clients), improve their quality of life, and increase access.

The metric for Value is Quality divided by overall Cost. Quality is the effectiveness of (a) treating illness/dysfunction treatment (as measured by risk-adjusted clinical outcomes, such as changes in a patient’s signs and symptoms); (b) preventing illness/dysfunction (wellness); and (c) stabilizing chronic conditions (disease management). Overall costs—including the cost of meds, tests, treatments and equipment/devices—rises because of inefficiency, waste, errors/malfunction resulting in additional care, excessive tests and procedures, over-prescribing, excessive risk, failure to select good lower cost alternatives, administrative & operational overhead (including malpractice insurance), etc.

From a consumer’s perspective, therefore, greater value care is more cost-effective care.
I contend that we should all be focusing how to increase healthcare value by:

• Rewarding providers and manufacturers who deliver higher-value services and products
• Enabling physicians and other practitioners to deliver high-value care through health IT, care coordination, ongoing clinician-researcher collaboration to build and evolve value-enhancing evidence-based guidelines, etc.
• Enabling consumers to distinguish between high- and low-value services and products
• Reducing providers’ economic burdens by lowering medical school costs through subsidies and malpractice insurance rates for high-value providers.

This is the essence of a “Value-Pricing” (Pay for Value) model of healthcare; it is a sensible alternative to the insane open-ended fee-for-service (pay for volume) model and the restrictive salary-only model.

The policy wonks, healthcare providers, researchers, payers and consumers ought to be debating how to make Value-Pricing a reality since it is the only rational way to achieve the ultimate goal presented above. All other conversations simply miss the point!

Related posts:

Healthcare Reform "Value Promotion & Reward" Strategy
Healthcare Reform Models Focusing on Value to Consumers - Part 1
Healthcare Reform Models Focusing on Value to Consumers – Part 2
Healthcare Reform Models Focusing on Value to Consumers – Part 3
Four Interlocking Issues about Fixing American Healthcare
Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Pay for Value

Federal Health IT Strategic Plan for 2011-2015: Comments

The Office of the National Coordinator for Health Information Technology (ONC) is seeking public comment on the Federal health IT strategic plan for 2011-2015. On their Health IT Buzz blog, they listed five goals that they hope will "unlock the vast promise of electronic health information to improve decision making, help individuals better manage their health, and improve the health system’s capacity for rapid learning. Following is a comment I posted there.

As a healthcare clinician (psychologist), researcher and health IT inventor/developer who has been focused on such issues for 30 years, the ONC goals, in general, are acceptable to me. Assuming, however, that providing ever more cost-effective (i.e., high-value) care to the patient/consumer is—or at least it should be—the overarching objective of the ONC strategy, then the following issues ought to be clearly addressed, imo.

One issue is the need for clinicians to collaborate with researchers and IT technicians via loosely coupled social networks (that cross professional, regional and organizational boundaries). The clinicians should primary care physicians and specialists across all settings, from in solo practice to large hospitals and integrated care organizations. They should deliver all types of healthcare, including conventional and CAM “sick care,” as well as “well care” (focused on prevention, health optimization and self-maintenance). These diverse groups of professionals would represent a “whole-person integrated care” approach that addresses biomedical, psychological and mind-body (biopsychosocial) factors/problems/conditions.

The clinicians in these collaborative networks would do two important things:

1) They would use health IT tools that build a research data warehouse with process and outcomes data, as well as lessons learned. This information exchange must be done securely and protect patient privacy.

2) They would also share and discuss ideas to guide the evolution of health IT by, for example, defining:

• Information models that depict what need to know and how they need the information presented;
• Where the information comes from (e.g., input by the clinician/office staff or received directly from the patient via a PHR);
• Ways to use the IT tools so they fit it into clinical workflows; and
• The kind of decision support they would want to receive (such as “patient-centered cognitive support,” [Reference].

The researchers, in turn, would generate evidence-based results by performing aggregate analyses on the patient and treatment data in the data warehouse, along with any relevant data from controlled clinical trials and lessons learned shared from everyday clinical practice.

The researchers and clinicians would then collaborate to transform the results into patient-specific recommendation in the form of preferred practice guidelines, protocols and clinical pathways. These recommendations ought to go beyond comparative effectiveness and focus on cost effectiveness [Reference].

The IT technicians would incorporate these recommendations into clinical decision support systems (CDSSs).When clinicians vary from these evidence-based recommendations, a CDSS should (a) enable clinicians to justify why they was such variance, (b) track what was done instead and (c) determine how varying from particular recommendations affects outcomes and costs.

A second issue is the need for lifetime whole-person health records that use of different models to adapt clinical terminologies, data sets, analytics/rules, data input forms, reports/views and user interface to a clinician’s particular requirements. There should also be a way for patients to input data to, and receive relevant data from, their providers’ EHRs.

Finally, a third issue is the need for tools and policies that support “new models of care, such as patient centered medical homes and accountable care organizations, [which] must emphasize value-driving elements of advanced primary care -- enhanced access, better care coordination, use of health information technology to support care transformation, and payment models that reward coordinated care” [Reference]. This means, in part, changing the payment model to one that incentivizes clinicians who focus on delivering high value (cost-effective) care to their patients by paying more to clinicians who take the time to use EHRs, CDDS, participate in the social networks discussed above, and focus on demonstrating continuous improvement in both quality and efficiency.

Enabling EHRs to Improve Care

In last month’s Archives of Internal Medicine, researchers at Stanford University released results of a three-year study that found EHRs in the ambulatory setting did not improve the quality of care [Reference]. There are, however, a number of limitations to the study, including the use of process measures (what was done) instead of outcome measures (the results of care) to measure care quality, the use of data that was collected around five years ago, and the fact that the doctors’ ability to use the EHRs properly were not assessed. Nevertheless, the study’s results do raise serious concerns.

To me, these findings are no surprise. I wonder why anyone would assume that today’s minimalistic and immature EHRs (in which I include EMRs)—along with a healthcare system largely based on pay-for-procedure/fee-for-service economic models—would boost care quality or efficiency. I’m not saying EHRs can’t help improve care dramatically; instead, I’m asserting that EHRs must be greatly enhanced—in both their usefulness and usability—before significant benefits can be realized.

The core issues, as I see them, are (a) EHRs’ failure to provide patient centered cognitive support and (b) our economic model in which financial incentives, such as pay-for-performance, fail to promote better quality [Reference].

One thing that’s needed is much better clinical decision support (CDS) from next-generation EHRs. The EHRs should provide CDS based on ever-evolving, individualized, evidence-based guidelines and pathways that focus on increasing value to the patient. In addition, the EHRs should deliver to researchers comprehensive (de-identified) data collected from everyday clinical practice. The researchers would use these data, along with controlled clinical trials, to develop and continually improve personalized CDS guidelines/pathways supporting diagnostic and treatment decisions for physical and psychological sick-care and well-care (prevention).
The other thing needed is to incentivize providers who deliver high value (cost-effective) care to the patient. Data from the EHRs would be used to calculate such incentives.

Constructing the Ultimate EHR

I just started a discussion on LinkedIn that focuses on answering the questions: How can the EHR be transformed into the cornerstone of a comprehensive health IT system that fosters continually increasing care value (cost-effectiveness)? This “Ultimate EHR” discussion follows a discussion at LinkedIn in which reasons for EHR failures have been examined thoroughly. The purpose of the current discussion is to use the knowledge of such failures to guide the construction of a blueprint of an EHR that helps providers achieve the best possible outcomes at the least possible cost. The link to the discussion is: http://linkd.in/hUPJqf

Here's the introduction

In addition to discussing conventional methods, participants in this discussion are encouraged to present their innovations, creative ideas, and novel strategies. We will examine and critique these technologies, concepts and approaches in order to define a next-generation EHR that helps transform clinical data into actionable information and evidence-based knowledge aimed at increasing healthcare value (quality and efficiency) ; e.g., see http://bit.ly/eal8CS and http://bit.ly/hoQKTG.

We will seek creative solutions to daunting challenges such as determining the best ways for EHRs to:

• Evaluate data integrity to help assure the data contained are valid
• Securely exchange patient data between disparate “silos”
• Build lifetime medical records that provide the specific information tailored to the need of clinicians from every type of specialty/discipline, and in every healthcare setting, through use of different models that adapt the clinical terminologies, data sets, analytics/rules, forms, reports/views and overall UI to the end-users particular requirements
• Promote a strong and productive link between scientific research and clinical practice (“bench to bedside”) by (a) delivering de-identified patient data from everyday clinical practice to central repositories where researchers use them in developing evolving evidence-based personalized guidelines (http://bit.ly/giw1kF) and (b) propagating those guidelines—using clinical decision support functionality—without fostering “cookbook” medicine or stifling innovation
• Improve decision-making by providing patient-centered cognitive support (http://bit.ly/EzWgF)
• Manage expansive and every-changing clinical data standards, including terminologies, care processes and outcome measures
• Support the delivery of “whole-person integrated care” (http://bit.ly/7BVuA5)
• Handle images of all kinds (http://bit.ly/hu3NCH)
• Interoperate with other health IT tools
• Accommodate ALL meaningful use requirements, now and forever?

 All questions, comments and ideas are welcomed.

Healthcare Reform Models Focusing on Value to Consumers – Part 3

My two previous posts (starting at this link) and this one discuss on how to bring high value to the healthcare consumer. I examined the two important models of healthcare delivery--the Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs)--and explored meaningful financial incentives models. In this post, I discuss issues concerning health information technology (HIT).

I defined high-value healthcare as cost-effective products and services that keep people well and improve the health & wellbeing of people who are ill. Providers (clinicians and healthcare organizations) who want to deliver such high-value healthcare require more than a desire to give their patients top quality affordable care. They also need a wealth of knowledge about the best way to prevent, diagnose and treat a wide range of health problems. This not only means continually learning, but also having access to latest evidence-based research and the guidance needed to use one’s knowledge in a way that fosters the best diagnostic and treatment decisions.

The only way to achieve high-value healthcare is to reform our current healthcare system, so it focuses on these two goals:

• Enabling all clinicians to continually learn how to make (and keep) their patients healthiest and happiest for longest, using the most cost-effective methods of treatment and prevention, and encourage/reward them for doing so.
• Enabling all consumers/patients to continually learn how to make (and keep) themselves healthiest and happiest for longest, using the most cost-effective methods of self-care and self-maintenance, and encourage/reward them for doing so.

Such a high-value healthcare system presents daunting challenges, however. One is being overload with overwhelming amounts of new information appearing daily. Another is the limited capacity of the unaided human brain to acquire, retain, recall and apply complex information about the human body and mind. See, for example, this link about the knowledge gap. Add to this the fact that we have a broken healthcare system full of perverse incentives (e.g., pay for procedure/volume rather than for delivering value), and there’s little wonder why healthcare in America is lower quality and much more expensive than in many other countries.

One crucial element of a high-value healthcare system it the sensible use of advanced HIT. That’s because HIT has the potential to bridge the knowledge gap and foster providers’ ability to deliver higher value care. The HIT industry, however, is having difficulty understanding what has to do; it has largely failed to develop the tools providers and patients need to increase healthcare’s value.

Consider this: The cornerstone of HIT—the electronic health record (EHR)/electronic medical record (EMR)—has been around for about 30 years. One would think, therefore, that today’s EHR/EMRs are successful. Well, knowledgeable experts have been having a great discussion at the HIMSS Linked-In group about this topic, with well over a thousand comments posted thus far. While some of the commenters believe that EHR/EMRs have been successful, most do not. The group gave many reasons for their failure, which focused primarily on technology, people and money.

From an HIT perspective, I indicated that before we can discuss EHR/EMR success or failure, we should first describe its primary goals. We could then determine whether the tools are achieving those goals. I therefore created a chart that defines three levels of EHR/EMR capabilities (weak, moderate and strong), the requirements for achieving success at each level, and the degree of usefulness of each level.

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