Thursday, May 8, 2008

How Can Health Information Technology Be Improved in Support of Chronic Illness Care?

It’s not every day that someone from the Department of Health and Human Services emails the author of the Disease Management Care Blog for recommendations, but that’s what happened. The DMCB was asked about enhancements to Health Information Technology (HIT) in the coordination of care for persons with chronic illness.

In this context, the DCMB thinks of HIT as a computerized health record (EMR, EHR or PHR etc) with a registry and decision support. With that simplistic generalization, it is happy to immodestly blog in with a bulleted summary of the recommendations below.

HIT is necessary but not sufficient. Even if near-term fixes in a) interoperability and b) competitors’ willingness to share data succeeds, there still isn’t a plethora of good evidence that upcoming versions of HIT will truly reduce costs or increase quality. Rather, HIT’s greatest potential lays in its support for other quality initiatives, including P4P, the Medical Home, CDHPs and Disease Management. It is the means to an end, not the end. Bottom line: ‘Cornerstone’ it’s not. Think mortar.

One reason why small physician groups have been reluctant to buy into HIT is because they bring their ‘front-line’ skepticism (some may say cynicism) in looking at its true value for their patients with chronic illness. Maybe they know something. CMS can always force the issue by regulatory fiat, but that won’t answer that nagging question: ‘where’s the beef?’ Bottom line: use your fiat power to also ask the HIT community to demonstrate it can deliver a tangible impact on outcomes in small group settings.

Limited (e.g., medication prescribing), cheap (not tens of thousands of dollars), modular (order entry this year, billing next year) and easy (plug and play) is more attractive than single solution, pricy, soup to nuts and complicated. Note that disease management vendors, in their eternal quest to achieve physician buy-in, are betting on the luster of turn-key web-based EMR solutions for their patients with chronic illness. Bottom line: accommodate the KISS concept in HIT.

[Sigh] RHIOs didn’t quite work out. The lesson is that parts of HIT may fail because there is still a market, albeit an imperfect one, that can separate the sustainable from the unsustainable. At a recent conference, the Secretary was heard to mention the interest of the Medicare program in “personal health records.” Uh oh. Bottom line: Keep in mind that the adage ‘don’t just stand there, do nothing’ can also apply to the world’s largest health insurer.

The notion of ‘medical records’ is changing. It’s no longer just provider-encounter and insurer-claims data, but the information being held by employers (e.g., sick days) and wellness (e.g., health risk assessments) and disease management vendors (e.g., the remote telephonic coaches record everything). The solution may be ‘personal health records’ but maybe not. Assuming they don’t achieve 100% penetration or 100% information capture, they’ll probably make things even more complicated. Bottom line: Update the existing HIT policies, requirements and protections to include these other emerging and disparate data bases.

Last but not least, the DMCB returns to the concept of ‘open data.’ Useful parts of beneficiaries’ patient clinical, pharmacy and financial data bases could be placed in the public domain for access by professional and amateur researchers. While this may be a radical concept, desk-top technology and the growing sophistication of researchers outside the traditional mainstream can generate insights on behalf of the public good. This is not an insurmountable concept if a) access is limited, b) if the right kind of patient protections are put into place and c) patients agree to it. Bottom line: join the open data movement.

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