Posted 11/2/11 on the Disease Management Care Blog
The Disease Management Care Blog remembers when it was first introduced to an electronic health record (EHR). After many days of learning how to document, link, retrieve, order, manage, view, bill, sign-off and close patient encounters, it asked about retrieving summary statistics on its patient population. It wanted to know how many if its patients with high blood pressure were under control and how many of its patients with heart disease had low cholesterol levels. The practice administrator looked at the DMCB like it was crazy.
That was when the DMCB realized that the purpose of its EHR had less to do with quality, costs, coordination and everything to do with perpetuating the “hamster wheel” of one-on-one primary care. Prior to the EHR, it averaged about 4-5 patient visits per hour. After the EHR, that didn’t change. Neither did its HEDIS® measures, patient satisfaction rates or professional well-being. The only thing that increased was its cumulative billing amounts. No wonder the DMCB has been an unrepentant EHR skeptic. It concluded that the purpose of the EHR is to perpetuate the dysfunctions of one-on-one care.
Articles like this, however, may change the DMCB’s mind. Jennifer Frankovich, Christopher Longhurst and Scott Sutherland describe how they tapped their local EHR’s multi-year database to assess the outcomes of a cohort of patients that was similar to one of their own. After analyzing how prior patients under similar circumstances fared, they decided that it would be a good idea to treat their patient with a blood thinner. The patient ended up doing OK.
1. Normally, a physician’s expertise is built over the course of many patient encounters. That’s called “clinical wisdom.” Being able to compact years of an institution’s collective experience from an EHR into a spread sheet is not only a step in the right direction, it’s using the EHR to build an institutional body of wisdom.
2. This is another case study on the important distinctions betweenobservational data bases (imperfect but locally relevant and readily available) and pristine evidence-based prospective randomized clinical trials (the gold standard for collecting evidence that is often lacking). The latter is the standard of care and the enemy of the good; the former is quite useful and, as this case shows, often good enough.
3. Last but not least, this is a good example of “applied” “population health management” in which a virtuous cycle of measurement can drive the local standard of care. It’s not only true for patients with obscure and rare diagnoses but for those with common, chronic and expensive conditions. Want to reduce the burden of obesity? Understand what really works for diabetes? Tackle the costs associated with hypertension? Assembling and using an electronic data base like this will make it possible.
The DMCB is looking forward to when future EHRs can perform at this level everywhere all the time.
Jaan Sidorov MD writes at the Disease Management Care Blog.