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.) 

Facebook, Patient Rights and Medical Records

The European Union is going to put legal pressure on Facebook to ramp up their privacy disclosure and protection, including the Facebook Right to Be Forgotten.  I have a feeling that the same right will someday be extended to a patient's medical record, no matter what the content.

Once upon a time at Northwestern University, I helped build the curriculum for an "Ethics in Medical Informatics" class, and I would occasionally return to give guest lectures.  I enjoyed all of the classes that I taught and those that I lectured, but the ethics class was the most fun.

One of the questions I would pose to the ethics students was based on a true story.  In 1999, a wealthy and successful business woman requested that her high school era abortion be stricken from her medical records at the local hospital.  She didn't realize that the abortion was part of her current record because the procedure was performed at another facility, in secrecy.  But, in a somewhat passing comment to her primary care physician about the abortion some years later, he entered her comment into her medical record...and there it stayed unknown to her until she requested a copy of her record be transferred to another facility for a referral surgery on her lower back.  I note the year because in 1999 nobody was talking about patient rights as they related to electronic medical records.  The prevailing belief at that time was that those records belonged to the hospital or doctor.  Can you imagine this poor woman having to argue with a hospital administrator over an already very embarrassing part of her life?  Can you imagine a pompous-- definitely pompous-- male hospital administrator forcing her to participate in several meetings to discuss the situation, in the presence of other hospital staff, and then asking her to put her request in writing and then forcing her to sign a release and indemnity?  After this hideous journey to arrive at what should have been an easy decision, the actual deletion of the information from her electronic medical record was technically very challenging because virtually all electronic medical records in existence then and now are designed to make true deletions nearly impossible, due to the overly conservative interpretation of laws that govern medical record auditing.  The best that you can easily do is hide something in an electronic record, but the audit functions prevent the data from actually being deleted.

About two-thirds of the students in each class would consistently vote to defend her right to remove the entry from her record, while the remaining third would defend retaining it as medically important to her safe care and the right of the hospital to know everything necessary to offer the best care, in protection of their reputation and standing. I'm in the two-thirds.

How far will we go in the future to allow patients full rights to edit their medical records?  How far do we go now?  Does it depend on the mental faculties of the patient?  How will we decide which patients are intellectually capable of editing their records in such a way that it won't place their healthcare at risk?  Should society care if these patients place their own well-being at risk?  Should you be able to delete something from your medical record that might be used to deny your insurance coverage, the ability to purchase a gun, or obtain a government security clearance?

Someday, personal health records will hopefully turn all of this debate of content ownership upside down, but we have a long way to progress in the industry-- many years-- before we reach that point.

That ethics class was a lot of fun.  :-)

Vermont Single Payer System-- A Role Model

Below is a link to an excellent article published by the New England Journal of Medicine on healthcare reform in Vermont.

This feels like the closest thing to a role model system for the US that I've seen so far.  In particular, it balances the local vs. federal control issue that offends so many people in the US.  The losers are the private insurance companies, but I've always been a fan of disintermediation of private payers in the healthcare industry, so in my opinion, removal of them from the economic model is positive over the long term.

Vermont Single Payer System

Accountable Care Organizations: Academic Medical Centers are in Trouble

Big Myth: Academic medical centers-- that is, universities that have a medical school, teaching hospital,  faculty practice plan, and receive substantial research funding from the US government-- provide the best care at the lowest price.  

Wrong.  They provide great unique care-- for example, treatment of rare diseases or complications-- and they provide reasonable care for common diseases but at a very high price.  For more common syndromes and diseases, you are better off going elsewhere for your money-- places like Intermountain Healthcare in Utah and Advocate in Illinois.   

Unlike Intermountain, Advocate-- Carolinas, Kaiser, Geisinger, Group Health and Fairview Health, too-- which measured and balanced their clinical quality and cost-of-care for years, most academic medical centers are barely getting started measuring anything.  Their measure of success is research funding per year-- and I mean that quite literally.  AMC's have long measured their success by the amount of research funding they receive each year, particularly from the National Institutes of Health.  You could argue that higher research funding implies better research-- even that's a stretch-- but even if you accept that argument, there is no denying that it typically takes several years at best for that research to translate into meaningful and better care for most patients.

By accident or by design, I'm not sure which, the Obama administration is the first to shine a spotlight on this disparity between cost and quality at AMCs—and now they have a rocky road ahead to change their culture, quickly.  If AMCs traded in stocks, I’d rate them a “Sell” right now.

This Feb 17, 2011 article (link below) from the New England Journal of Medicine is a good overview of the cultural challenges ahead for AMCs.  Note that Johns Hopkins, discussed in this article, has its own insurance company, which makes it very unique among AMCs, because by managing its own insurance company, Johns Hopkins must manage both the cost of healthcare and the quality of healthcare that it delivers, otherwise placing its own insurance company in financial peril.  That's the key point:  AMCs must feel the financial pressure to deliver better care, in general.  Right now, they really don't.

Accountable Care Organizations & Academic Medical Centers

The Cayman Islands ACO Roadmap

We are implementing a new care delivery and economic model called “CayHealth” which, at a very high level, seeks to maximize the quality of care delivered while assuring an economically sustainable healthcare system for the Cayman Islands. CayHealth is very similar in nature to the emerging Accountable Care Organizations (ACO) in the United States. We expect HIT vendors involved in the Cayman Islands to offer solutions which clearly and naturally support CayHealth concepts and requirements, as described in the maturity roadmap below. Those of you familiar with the recently released Premier ACO Roadmap will see some similarities, but the two efforts were developed independently, which is a good indication that there is a convergence of professional opinion on the future of healthcare which crosses international borders. Each level of maturity builds upon the functionality of the preceding level.

Level 1: Clinical Efficiency

Data collection regarding patient encounters is optimized for clinician efficiency and outcomes analysis. Narrative text is facilitated through the use of templates, computerized order sets are directly driven from evidence-based medicine, and discrete data collection supports national and international benchmarks for clinical quality at the clinician and organizational level. Clinical productivity is easily measured and reported. All internal orders are electronic. External pharmacy orders are also electronic. A patient-centric web portal disseminates lab and other diagnostic results and clinical reminders. Positive patient identification occurs through card swipes or biometrics and also supports electronic eligibility verification. Claims submission and payment processing (including reimbursement) is completely paperless. The economics of reimbursements remains primarily procedure-based and fee-for-service. Mobile healthcare applications are pervasive for enhancing clinician efficiency, quality and timeliness of care, and patient engagement in their own care. The user interface of the EHR is highly and easily customizable through widgets and gadgets, giving clinicians significant control over configuring the user interface that suits their preferences best.

Level 2: Communication and Economics

The EHR elegantly facilitates closed-loop care-team coordination and communication regarding patient status and pending activity. Reminders for health maintenance are electronically pushed from the EHR to the patient and automatically schedule follow-up appointments and procedures. The referral process is facilitated by that ability to choose, schedule, and communicate with referral physicians electronically. Disease management reports are native to the EHR and push reminders to physicians and patients. Patient management is based upon disease and risk registries that come bundled with the EHR and can be locally customized. Clinical reminders about patients are pushed to the responsible members of the care team, including family members, if desired. Clinical documentation and billing processes are now dominated by capitated, per-patient-per-month reimbursement models. Insurance implications and Total Cost of Care assessments are facilitated by the EHR, enabling point-of-care discussions about projected costs, outcomes and treatment options between patients and physicians. Quality of care reporting is natively supported by the EHR and patients and physicians are financially rewarded by insurance companies and direct contract employers for achieving health-related goals. The EHR and HIT financial applications are designed to support this economic feedback model. Personal health records are widely used by patients and the care team, including health coaches and case management professionals. Patients’ health maintenance plans are based upon computerized health risk assessments. E-prescribing with local pharmacies is full-duplex, allowing for medication reconciliation. Systemic monitoring and notification of abnormal test results ensure closed-loop communication with the care team and patient.

Level 3: Pervasive Analytics & Health Monitoring

Quality of care dashboards are fully integrated with the EHR which allow clinicians to move seamlessly between population-based monitoring and patient-specific care delivery. Population-based and patient-specific health status reporting from remote monitoring devices, videoconferencing and mobile self-reported outcomes support the health management of many patients, regardless of location, by relatively few nurses and physicians operating from a “Health Command Center”. The EHR’s analytics engine natively supports reports for proactive profiling and management of high-cost, high-risk, high-utilization patients. The EHR is beginning to accommodate Personalized Medicine. Genetic and familial tendencies are easily recorded and displayed for reference in the EHR.

Level 4: Social Wisdom

Content and analytic feedback is integrated into the care delivery process of the EHR which allows clinicians to answer:

• Which of my colleagues has seen patients like mine?
• How were patients like mine most commonly treated?
• What were the outcomes of treating patients like mine with this clinical protocol?
• How did patients like mine rate their care delivery process and outcome?

Patients are engaged in this social wisdom dialogue through their Personal Health Record and mobile applications are used to fully-engage patients in healthy lifestyles. EHR functionality exists to automatically update and notify clinicians to recommended changes in evidence-based protocols based upon the real-time feedback of diagnostic tests, devices, and patients’ self-reported outcomes.

Level 5: Personalized Medicine & Wellness

Personalized Medicine is fully integrated into the EHR so that generic evidence-based order sets and lifetime health maintenance plans are now tailored dynamically towards the genetic and familial tendencies of the patient. Remote monitoring and telemedicine/e-visits constitute at least 50% of the encounter types. EHRs facilitate the data collection and analysis of patient treatment and protocols so that hospital financial systems are capable of actuarial and risk forecasting to enable a growing trend towards self-pay, high deductible health plans, and employer direct contracting for healthcare coverage, reducing the dependence on third-party insurance.

Holding Vendors (and others) To Their Proper Accountabilities

In negotiations with poorly performing vendors, debtors, and/or employees, remember this thought.  It will come in handy:

"The unfortunate cause of your problems has my empathy, but does not in any way diminish my intolerance for the consequences nor lessen my insistence that the situation be resolved to my fair satisfaction."

If given a window of opportunity, many people will use the excuse, "It's beyond my control" to continue with the status quo.  Nothing that affects you is totally beyond your control.  By definition, if it affects you, you can do something about it.