Thursday, March 31, 2011

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.