The EHR Tipping point, HEDIS® Uncertainty Principle and the Hypoplastic Hypothesis

(From time to time, the Disease Management Care Blog welcomes commentary from its readers.  Here's an interesting thought.....)

As a long-term reader, I thought the erudite but contrarian and sometimes snarky DMCB might be the best venue to ask others of my ilk to comment on an observation of mine.

I am a primary care provider working at the quantum level of patient care.  I am in my second year of full fledged EHR use.  It is obvious to me from the consultation notes that I receive on an hourly basis that most of my colleagues are also on board.  Journal articles as well as my first-hand experience have convinced me that we have indeed reached the tipping point of electronic record use. 

Since this milestone passed, I have noticed a change in the focus of office notes and consults.  I am seeing neurosurgeons document conversations regarding the safety of patients relationships and whether or not they feel threatened.  Podiatrists routinely document the existence of living wills.  Dermatologists are now savvy about the sexual activity of octogenarians with actinic keratosis. Despite my consultants' thoroughness in their care (and conversations with health care students who have rotated through these specialties make me believe that some specialists are using telepathy to document things), I am not seeing traditional assessment and plans at the end of the encounter. 

What I usually see is the same generalized diagnosis code that I sent them with followed by a list of tests cluttered with a references to various quality metrics that are inspired by systems such as HEDIS®.  The old fashioned differential diagnoses or thoughtful prose concerning the evaluation is conspicuously absent. 

I call this my hypoplastic hypothesis.

As a primary care physician, when I consult a colleague, I am really asking the specialist “Hey, what do you think?” Prior to the advent of the EHR, much of my continuing medical education has come from the insights that I use to get from these consults. Now I'm reading about feeling threatened, living wills and sexual activity.
 
How did we get here?

When I was an undergrad in Biochemistry, during the dreaded Physical Chemistry course, we learned about the observer effect and the Heisenberg uncertainty principle. Wikipedia defines both as:

"In science, the term observer effect refers to changes that the act of observation will make on a phenomenon being observed. This is often the result of instruments that, by necessity, alter the state of what they measure in some manner. A commonplace example is checking the pressure in an automobile tire; this is difficult to do without letting out some of the air, thus changing the pressure. This effect can be observed in many domains of physics.....However in quantum mechanics, which deals with very small objects, it is not possible to observe a system without changing the system, so the observer must be considered part of the system being observed.

In quantum mechanics, the uncertainty principle is any of a variety of mathematical inequalities asserting a fundamental limit to the precision with which certain pairs of physical properties of a particle known as complementary variables, such as position and momentum, can be known simultaneously. For instance, the more precisely the position of some particle is determined, the less precisely its momentum can be known, and vice versa."

In my opinion we now have a new phenomena that parallel the laws of physical chemistry:  I call it the HEDIS uncertainty principle. 

The actual act of measuring HEDIS® scores and other similarly contrived quality metrics has fundamentally intruded into the quantum level of physician care.  Does this measurement change the behavior of the particles of the system and alter the ultimate structure of the encounter?  Are the data still reliable and the measurements still accurate?  Have the impressions and treatment recommendations indeed become hypoplastic, or has the encounter remained unchanged but the documentation is skewed to HEDIS®? Is the question asked of the consultant answered but not documented?  If not, what does this portend for disease management and health care quality?

I have my suspicions, but I would like to tap the wisdom of the DMCB readers for theirs.

Image from Wikipedia

The Tipping Point for Desktop Analytics: A Watershed Moment in the History of Health Care

Germ theory in 1860. The Flexner Report of 1910.  Zombie immortality in 2012  There are only a few watershed moments like these in the history of U.S. health care and, after hearing the other speakers at the recent Star Ratings Congress in Las Vegas, the Disease Management Care Blog thinks it's found another one.

 It calls it "desktop analytics."

In its early health services research career, the DMCB's studies consisted of creating study protocols that included data collection and storage, very high end computing, statistical planning and a carefully contrived reporting format. The timeline typically spanned over several months, required high end computing, involved fussy Ph.D. level statisticians unaccustomed to exceeding customer expectations and ultimately having to convince a narrow, highly educated, and skeptical audience of the veracity of the DMCB's conclusions at a scientific meeting.

While that is still necessary in traditionally funded research studies, the story is now far different in mainstream health care and insurance settings.  Tapping electronic record or insurance claims data bases are now far easier. Statistical software packages are do-it-yourself and 'walk' users through the basics. Ph.D-level statisticians are unnecessary. Mainstream health workers have a working appreciation of measurement as well as trending and the folks inhabiting the C-suites use their in-house research conclusions in core business planning.  And it can all be done using desktops that cost a few hundred bucks.

At the Star Ratings Congress, the DMCB listened to speaker after speaker who presented highly polished insights about quality and cost that were developed thanks to in-house information systems and analytics resources that would have been unthinkable a decade ago. This advance in data management has enabled providers and payers to spot trends on a month-to-month basis, compare local performance to historical as well as national benchmarks and report outcomes to external agencies on a regular basis.  The research efficiency was astonishing.

It was also so taken for granted. It shouldn't be.  Compared to 10 years ago, the industry has gone from the wheel and fire to the internal combustion engine and automatic transmission.

The DMCB thinks its going to get better too.  While the electronic health record vendors have been notoriously inept at supporting data analytics, it's going to just be a matter of time until community-based providers can hit a function key on their keyboards and scan (for example) mammography rates by age, race, zip code and months since last visit.  Insurers will be able to project which enrollees with diabetes on three or more prescription drugs are least likely to take their medicines after controlling for co-pay and weather.

When we finally do figure out how to increase quality and reduce costs, it'll be because desktop analytics had finally reached the tipping point.

Coda: This has important implications for the Affordable Care Act's Coordinating Council for Comparative Effectiveness Research.  The Council may find that by the time a prospective CER study is complete that desktop analytics had already found the answer and the much of the industry had moved on.  Stay tuned.

Hypertension, HEDIS, Excessive Blood Pressure Lowering, Polypharmacy and Implications for Care & Disease Management

Just what do the two numbers in a 'blood pressure' (for example, 120/80) really mean? What happens if the pressures are too high? Suppose just one number is high... how should it be addressed? How should the quality of care be measured among persons with an elevation in just one number? Can overzealous pursuit of high blood pressure lead to bad outcomes and, if so, how should that be measured in populations?

Thanks to a recent publication in the American Journal of Managed Care, your Disease Management Care Blog addresses the controversy.

The DMCB thinks of the two numbers as the highest and lowest measured pressures in the body's arteries that are generated by each heart beat. When the heart muscle contracts, the pressure increases until it peaks. Then the heart relaxes to fill with blood for the next pump. The blood pressure falls during this time until the heart begins to squeeze again. Therefore, think of 'blood pressure' as the peak increase and bottoming out of the pressure that is generated by each heart beat. Most of the time, a person's blood pressure is in between the top number (the systolic blood pressure) and the bottom number (the diastolic blood pressure). We're constantly bouncing between the two extremes.

It's been known that most people seem to have a peak or systolic blood pressure of 120 millimeters of mercury and a bottom or diastolic blood pressure of 80 millimeters of mecury. When those pressures increase, there is increased wear and tear on the inside walls of the arteries, leading to heart attack, strokes and kidney disease. Among persons without diabetes or kidney disease, decades of research have shown that a blood pressure of more than 140 systolic or 90 diastolic (the short hand being '140/90') results in significant enough damage to warrant treatment. If diabetes or kidney disease is present, the treatment threshold numbers are even lower at 130/80.

Which brings us to today's population-based care management conundrum: what should patients and treating health providers do with the category of high blood pressure where there is an elevation in only one of the two blood pressure measures? The reason that is important is because treating one high blood pressure number may cause the other to become dangerously low. For example, (when diet and exercise are not enough) pursuing a systolic blood pressure of 130 or higher with drugs in a person with diabetes could result in their normal diastolic blood pressure going below 70. According to this paper (the info is summarized on Figure 1), that can lead to an increased risk of heart attack and stroke.

This is not just a question for patients, providers or disease/care management organizations. It's also an important wrinkle in the national pursuit of health care quality. For example, a strict interpretation of the National Committee for Quality Assurance (NCQA) HEDIS® measures for successful blood pressure control suggests all persons with diabetes should have blood pressures less than 130 systolic and less than 80 diastolic - with no allowance for the unlucky patients with a 'successfully' treated systolic pressure that is less than 130, causing a concurrent diastolic blood pressure below 70.

Another criticism of the hypertension NCQA HEDIS® measure is that it doesn't recognize that sometimes blood pressure pills simply don't work. Most clinicians stop prescribing additional medications when the patient is on three. Once a patient reaches that point, additional pills are unlikely to work but are more likely to cause side effects.

This can be a problem, because 'all or nothing' blood pressure quality like less than 130 and less that 80 metrics - while well meaning, relatively simple to measure and based on the science - fail to capture the more subtle realities of of hypertension care that are also tied to outcomes (like excess heart attacks) and quality of life (medication side effects).

Which is why this paper published in the latest January 2010 American Journal of Managed Care is important. The authors looked at nine community-based general internal medicine clinics' patients 'of an unnamed academic healthcare system,' thanks to having access to an 11,000 person registry that captured the blood pressure (BP) readings of each and every patient. Two pools of patients were studied: 125 with diabetes who had a recent BP that did not meet the HEDIS criteria of less than 130/80 but were less than 140/90, and 125 patients with BPs or 140/90 or greater. In examining their electronic medical records, they found there were 31 (or 25%) patients in the first pool that were taking three blood pressure prescription medications and/or had a diastolic blood pressure less than 70; there were 43 (34%) patients in the second pool on three or more prescription medications and/or had the low diastolic blood pressure. Among those aged more than 65 years, the numbers were even higher: 58% in the first pool and 60% of those in cohort B took 3 or more antihypertensive medications and/or had the low diastolic pressure.

From a pure unrefined HEDIS® measurement standpoint, having a quarter to one thrid of patients with 'out of control' blood pressure would look bad. DMCB readers have long known there is more to the story. This AJMC study helps us understand the problem better.

The NCQA's Executive VP Greg Pawlson and Partners Healthcare's Thomas Lee would seem to agree. They penned an accompanying editorial in the same issue of AJMC that explains that when it comes to quality measures like those used by the NCQA, '100% performance is not the goal... that clinical judgement should be used' in applying the measure to populations and not be used to 'dictate the care of any individual patient.' They also suggest that the NCQA is open to modifying its measurement guidelines and look forward to the day when real time registries can provide more detailed measurement options.

Hear hear says the DMCB.

What does this mean for disease management organizations (DMOs)? Since DMOs also typically maintain high performance registries, they should already have access to the level of detail that can not only report the standard 'blunt' HEDIS® measures but also gauge the level of polypharmacy over-treatment or excessive BP lowering. Being able to educate your customers about these subtleties and report these data will be a competitive advantage, especially if the NCQA modifies its HEDIS® criteria.

The Mammography Controversy: How Government Runs An Insurance Benefit

What took the the US Preventive Service Task Force so long?

Years ago, the young and inexperienced medical director Disease Management Care Blog became aware of a burgeoning body of literature (examples here and here) questioning the value of mammography for women less than age 50 years. Its health plan considered the option of denying coverage of mammograms in this age group, but ultimately decided against it. We calculated that the HEDIS, marketing, public relations and political downside of reducing a women's health insurance benefit was just too radioactive in our network. Based on an assessment of what our customers wanted, we put that idea down and slowly backed away. Problem solved - quietly and more than 10 years ago.

The 2009 mammography controversy shows how difficult it is to create a one-size fits all insurance benefit that reconciles the a) science, b) market expectations and c) politics. As government increases its role in the nation's health care, readers can expect the same slowness and rhetoric to intrude into countless other coverage decisions.

In a perfect world, women could choose an insurance plan that meets their price point (the monthly premium) and benefit plan (mammograms expensively covered every year vs. another less expensive option). As we all know, all Americans should have anything they want, just so long as they pay for it. Ms. Sebelius is once again reminding us that in rhetoric-driven government dominated health care, all Americans should have anything they want, and we're all going to pay for it.

One last point: this should give readers some insight into HHS Secretary Sebelius' pain. Ironically, during her confirmation hearings Sebelius was roughed up by Senators who were fearful that she'd use comparative effectiveness research to interfere with the doctor-patient relationship. Her flexible stance on mammography shows she is keeping her word.

All things considered, good for her.

Physician-Focused HEDIS Is Not Enough

The curmudgeonly Disease Management Care Blog recently provided input on some proposed preventive care measures for HEDIS. While it thinks the proposed methodologies are sound, are helpful and should go forward, it remains unconvinced that physician-based promotion and prevention is really really up to the task. Brief counseling makes a difference, but doctors fall short of consistently providing necessary wellness and prevention counseling in areas such as adolescent tobacco use, alcohol abuse, HIV prevention, osteoporosis treatment, cardiovascular disease in diabetes and obesity. What are the docs trying to tell us?

Surveys have demonstrated that individual physicians prefer to independently review the science that undergirds many wellness and prevention guidelines for themselves and, many times, agree to disagree. They may a) not have enough information, b) conclude the recommendations are in error, c) doubt that they have the necessary skills to carry them out or d) believe carrying them out the will make no difference. For some HEDIS measures, that's not unreasonable. Being human, if they don’t practice what they preach, they’ll also not preach.

The fix is not necessarily ‘payment’ as in performance (P4P). Other surveys have shown physicians can be ambivalent about the role of economic incentives and that many don’t buy into the notion that they should benefit if the patients’ outcomes are improved. Physicians may also doubt that commonly used measures of performance capture what is truly important. This dissonance may be particularly acute when they care for elderly vulnerable patients with multiple co-morbidities. No wonder there’s data showing P4P may have a limited impact.

And then there is the problem of trying to figure out just which physician is responsible for what. As pointed out in this article, patients (in Medicare fee for service, and by extension, in commercial PPO insurance products that don’t require a referral) may be seeing multiple physicians, each with a hand in the management of an aspect of prevention or chronic illness. Many people also rarely see physicians. If HEDIS, which is based on insurance claims and chart audits, can’t identify a responsible physician, is it reasonable to make physicians accountable?

There is also the emerging perspective that patients need to be equal participants in medical decision making. A distinct percentage of health care consumers may therefore decide, based on their goals, values and resources, to not follow through on the prevention recommendations of their physicians. Why should their physicians be held responsible if patients make a decision that is counter to HEDIS recommendations? Shouldn’t physicians be given credit for a) informing their patients of the recommendations (via chart documentation or by use of a special code) and then b) honoring their wishes?

What is the fix for skeptical physician-scientists that are human, resistant to blunt economic incentives, are interacting with a complex web of other physicians and letting patients decide for themselves? The DMCB doubts there is a magic mix of resources, incentives and sticks based on HEDIS measures alone that can be aimed at docs and appreciably change their prevention and wellness care patterns. Rather, it's time to invite other stakeholders to the party.

The DMCB recommendation: it's time to determine and accept the upper range of what is typically possible in physician-based prevention and wellness activities in usual clinical settings. Once that is understood, the sometimes successful use of HEDIS can be integrated with the promotion and measure of wellness and prevention in other sectors of the economy such as school districts, employers, communities, disease management programs, wellness providers and personal health record vendors. In the meantime, promoting physician reliance on the Patient Centered Medical Home's approach to 'outsourcing' prevention and wellness to other local team members may help increase clinic-based HEDIS measures.

Based on what we know about traditional physician approaches to wellness and prevention, is this necessary? Yes. Difficult? Yes. Naive? Yup. Outside the typical mandate of HEDIS? Absolutely. Do consumers deserve new approaches that build on the successful track record of HEDIS? Yes.

When should policy makers start working on this? ASAP.