Saturday, March 26, 2011

Intermountain Healthcare and EHRs



Before we go too far in assuming that you need an EHR in order to achieve what Intermountain has achieved in lowering costs and improving clinical outcomes, it’s worth drilling down a little further in the details.  It is Intermountain’s billing, registration, and case mix systems that enable much of what Intermountain achieves… and virtually every healthcare provider and system in the US already has a computerized registration, case mix and/or billing system of some kind.

Intermountain Healthcare garners oodles of much-deserved credit for delivering better healthcare at a lower cost than the average US healthcare organization, and they also receive credit for the role that their EHR, primarily the HELP system, plays in that achievement of better care and lower cost.  But it was data from their financial and case mix systems that was the backbone of their process improvement culture, not their EHR.  Instead, the Intermountain EHR environment played a major part in showing all of us what could be achieved with sophisticated computerized decision support—not necessarily system-wide quality and cost-of-care process improvement.  Through EHR applications like Storkbytes for fetal monitoring, the ARDS weaning protocols, the ICU glucose manager, and the particularly noteworthy Antibiotic Assistant, the industry learned that computers could be programmed to assist and benefit the delivery of care at the point of care.   That’s a much different use of computers and data than say, reducing the number of elective inductions, hemoglobin A1C rates, or readmission rates for patients with congestive heart failure or MI across the entire healthcare system of 23 hospitals and 100+ clinics.  The reality is, Intermountain's EHR is not pervasively adopted, yet.  The further you travel away from LDS Hospital and the new Intermountain Medical Center, the less likely it is that you will find Intermountain's EHR being fully used.  But… every facility uses a commonly-adopted billing and registration system.

Brent James and his team of incredibly capable data analysts have long relied on nicely structured case mix data to drive Intermountain’s quality vs. cost analysis—ICD codes, CPT codes, NDC codes, APR-DRG, admissions data, mortality data, charges, reimbursements, etc.  It wasn’t until the early 2000’s that Intermountain managed to pull large quantities of data from the HELP and HELP2 systems in such a way that the analysts on Brent’s team could benefit from EHR data.  Even then, the data from the EHR didn’t offer enormously more value to the data-driven processes and culture that were already in place.  If you think about it, what additional data does an EHR provide to healthcare process improvement that you can’t get somewhere else?  Progress notes, orders (not results… results come from other systems), vitals like BMI and BP.  Hmmm…. The value-add of this EHR-unique data isn’t all that high to most process improvement projects in healthcare-- I know this sounds like heresy at a time when we are throwing money at EHRs by the billions.

One of the most overlooked aspects of Intermountain’s success is the organizational structure they put in place to consume the data that Brent’s team (and other analysts such as those on the Enterprise Data Warehouse team) serves for dinner.  An often-overlooked leader at Intermountain in the creation of these organizational structures is Dr. David Burton, now retired.  With the patient deliberation of geologic forces, Dave Burton organized clinical process improvement organizations and leadership structures that started at the enterprise level, and worked their way down to the care delivery level.  Teams of organizationally-dedicated physicians, nurses, administrators, and data analysts were organized with the precision of a manufacturing plant in each of several different clinical programs—e.g., Cardiovascular, Women & Newborns, Oncology, Intensive Medicine, Primary Care, and Neuro-musculoskeletal—to establish goals, measure outcomes, measure costs, observe the measures, then change behavior towards those goals.  Without this highly-structured and goal-driven organizational structure, data will flow like water to a land without crops—nothing will change, nothing will grow.

All of this is not suggesting that EHRs don’t have their value at Intermountain or the rest of the industry—they certainly do.  What it does suggest is, that you don’t need to wait for an EHR to achieve what Intermountain has largely achieved in maximizing quality and minimizing costs at the systemic level.  You can go a long way down that path with the right organizational structure, highly capable data analysts, an enterprise data warehouse and boring old billing, registration, and scheduling data.

(Mr. Sanders served in various capacities during his 8 years at Intermountain, 1997-2005, including Director of Medical Informatics for Intermountain's largest region and chief architect and project manager for their Enterprise Data Warehouse.) 

1 comment:

Catmando said...

Indeed. You need more than technical solutions. You need cultural solutions. If the people in an organization are not committed to a systematic way to ask and answer questions, it does not matter what technology is spinning on the platters.

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