Saturday, December 6, 2008

The True Value of an Electronic Health Record

We still struggle to define the value and return-on-investment of EHRs, often times naively attempting to justify the investment based upon improvements to physician workflow and patient volume. The real value resides in the systemic value of the data that's collected, the data that's analyzed, and the data that is presented (or not) back to the physician at the point of care, that has been dynamically tailored for the context of the patient being treated, making it easy for physicians to do the right thing.

A few days ago, I was in a meeting with members of Virginia Mason Medical Center who were visiting Northwestern to discuss clinical analytics and process improvement. Northwestern's Dr. David Baker provided an overview of an AHRQ-funded project called UPQUAL (Utilizing Precision Performance Measurement to Improve Quality) which he is leading. I think UPQUAL is the most systemic example and role model of clinical quality improvement in an ambulatory setting that I've ever seen-- every step in the care delivery process is affected. You can Google "UPQUAL Baker Persell" and find references. Darren Kaiser, my Senior Technical Guru of All Kinds, has been a critical part of this project, too.

During a break in his presentation, Dr. Baker was speaking with members of VMMC. The conversation moved to the recent clinical study published in the British Medical Journal which indicates that prophylactic aspirin for diabetes patients without cardiovascular disease is not effective in reducing heart disease-- the risks of aspirin outweigh the benefits.

Later that week, I was browsing my bloated email inbox and came across a Change Control Summary from our Clinical Systems team, entitled "Turn off BPA for Aspirin in Diabetics." Hmmm.... I opened the message and read the description: "Unrelease BPA #92 "Consider Aspirin in Diabetes" per direction of Dr. Persell/Baker. Recent evidence suggests that this Best Practice Medical Guideline is no longer deemed a best practice. Hence, we don't want to trigger BPA recommendations when there is little benefit to patient care." Translated, this means that Dr. Baker contacted our EpicCare EHR team and asked them to turn off the Epic Best Practices Alert that reminded our physicians to consider aspirin therapy for our diabetic patients.

I talked to Dr. Baker later in the week and asked him for the background. As he described it, the General Internal Medicine physicians discussed the strengths and weaknesses of the BMJ article, and then voted in one of their regular Clinical Quality Committee meetings whether to accept the new evidence and adopt the changes in practice. They voted in the affirmative and closed the loop by contacting the EpicCare team who then changed the BPA.

From start to finish, this change in clinical protocol took about eight weeks. I think the BMJ article was published on Oct 3 and the EpicCare Change Control was implemented on Dec 5.

In various lectures and presentations, I frequently speak of this concept which I call "Mean Time To Improvement" (MTTI). It is the theoretical ability to measure the time it takes a company to recognize the need for improvement, and then take action to implement that improvement on a widespread basis. I give examples of process improvement in industries like the foreign automotive market, computer chip fabrication, PDA design, wireless cellular services, and leading retailers. The examples indicate that the MTTI among the leaders in those industries can be measured in terms of hours, days, and a few weeks. They have low MTTI cultures. Then I give examples of process improvement in the U.S. government, automotive, and healthcare sectors. There are individual heroic exceptions in each of these sectors, of course, but for the most part, the MTTI can be measured in months and years... maybe decades. For dramatic impact, I use the example in healthcare in which 17 years expired before the protocol for community acquired pneumonia (CAP) was commonly accepted and practiced.

You see where I'm headed here... in the specific case of removing Epic BPAs for aspirin therapy in diabetics with no existing cardiovascular disease, we have an example which momentarily drove the MTTI in healthcare down to levels of respectability amongst the best of other industries-- maybe even better than other industries. It exemplifies the true value of an EHR to healthcare-- if that EHR is configured and utilized up to its potential by quality-dogmatic physicians and a capable IT team.

Very cool.

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