Robert R. Reza II

HIT Improving Community Health Outcomes in Ambulatory CareINTRODUCTION

Currently America has the world’s most inefficient healthcare system when compared to other countries2, spending about 1.7 trillion dollars last year2. Moreover, America spends the most on healthcare and ranks about 27th when it comes to life expectancy as seen in the figure below.

Figure-1 Life Expectancy vs. Healthcare Spending

Figure 1 displays Life Expectancy vs. Spending, plotting various countries on the graph. As seen in the figure, America spends the most and has a lower expectancy than countries that spend less in healthcare such as Cuba or Japan.

Figure courtesy of reference3

Health Information Technology (HIT) poses a possible solution to this problem by promising major health care savings, reducing medical errors, and improving health as a whole2,

particularly in the potential seen in electronic health record (EHR) systems coupled with the idea of health information exchange (HIE) and the personal health record (PHR). This paper summarizes the potential that HIT has in improving community health outcomes through the use of EHRs, PHRs, and HIEs to monitor conditions, provide education, improve quality, and possibly aid in reshaping the health care system.

It should be noted that it is realized that there exist potential cons to this idea, some of which will be addressed here; however, this paper is meant to summarize the most optimistic view of a world with HIT. Also, in context to this article EHR are defined as a digital collection of a patient's medical history, including diagnosed conditions, prescribed medications, vital signs, immunizations, lab results, and personal stats like age and weight as stated by the U.S. Department of Health and Human Services1 and for the purpose of this paper it will be assumed that the EHRs are coupled with clinical decision support (CDS). In addition, PHRs are very much the same thing except managed by the patient and unable to conduct physician duties such as prescribing drugs and ordering test.

MONITORING/MANAGING/PREVENTION OF CHRONIC CONDITIONS It is estimated that patients with chronic illness absorb more than 75 percent of health

care dollars2, thus this is a major area that must be dealt with in order to improve health of the over all population. EHRs can play a major role in managing patients with chronic conditions especially through the use CDS, which allows the provider to be supplied with clinical

knowledge used to make better informed, quality decisions. One such application that can be done through the use of CDS is the generation of reports displaying trends of individual patients or the sum of all the patients in the provider’s practice over time. Generating such reports could show physicians where they could be more effective and if they should focus more on certain areas than other. For example, a physician could choose to generate a report showing the results of HbA1C tests across all of their diabetic patients on certain drugs over time and deduce which drug is most effective and prescribe accordingly. Taking this idea further, if interoperability between EHRs of all types were established and through the use of HIE, a government agency or qualified business could run a report displaying all the people that have a certain condition in a given population. Based on the results of these reports, proper action could be taken such as educating the citizens of a given population about a certain condition that is spreading in their area and provide them with proper precautionary measures and vaccinations. If such an example were to occur and actions were taken, this could reduce the possibilities of wide spread diseases, such as the tuberculosis; by controlling the disease/illness at the source, less people will acquire illness thereby improving the health of that particular population.

In addition, EMRs integrated with CDS could aid in taking preventive measures by providing recommendations for screening and preventative services by processing a patient data (family history, age, sex, ethnicity, and clinical patient history). Physicians could advise patients and make them more knowledgeable about conditions that they are more susceptible for. This could find possible risks that were unknown without the use of the EMR, and potentially make the patient more active in preventing illness at the same time stopping the illnesses before they even start. By controlling these conditions and possible infections, the consensus of a given general population’s health should theoretically improve.

PHR AND INTEROPERABLILITY IMPROVING QUALITY OF CAREPHRs allow for an amazing opportunity for patients to play an active role in the treatment

and prevention of possible conditions as well. As stated before, PHR are maintained by the patient and can include patient generated notes and clinical data from various sources of care. By making this record managed by the patient, the patient gets a more in depth perspective as to the severity their condition is, which may even cause them to seek their own research on their conditions. By making PHRs electronic and if they were to be interoperable with physician’s EHR system, their potential for improved quality becomes much greater in the way that it opens the door for a continuous type of care versus today’s type of care, episodic. Moreover, physicians could track the conditions of chronic patients based on up-to-date information as to how the patient is feeling and patient supplied data that are available, possibly leading to catching conditions early. On the patient side, it allows for patients to have access to their doctors by having an open door to communicate with them, thereby improving their relationship and instilling trust. In addition, it also allows for appointments, refill request, and appointments to be at greater convenience4. Furthermore, it would make patient-doctor meetings more efficient by allowing conversations to take place more focused on treating the patient versus finding out the patient’s previous history. This improvement in quality could lead to healthier people which in turn could create a healthier population.

Although, there is a considerable amount of potential for PHR/EHR integration, there are many barriers to this idea such as the issue of patient privacy, creating standards for interoperability, spreading awareness for adoption, and who will pay for this to be implemented4. It will take a considerable amount of time to debate this issue, as many of the issues also applies

to the implementation of national/regional HIEs, but it is believed that this can be achieved. However, in order to have this kind of a system that is based on quality care, the model in which doctors are currently paid must change; otherwise there is no incentive for the physicians to aid their patients outside the realm of an office visit.

HIT PAVING THE WAY FOR PAY-FOR-QUALITY MODELThe current method for reimbursing a provider for an episode of care is the fee-for-

service model. In this model, doctors get paid for the more they do for the patient, such as ordering more tests or having frequent follow-up visits, as opposed to whether the patient is actually improving in their health. The model must be switched to a pay-for-quality type model in order to get the full potential of EHRs, PHRs, and HIEs. EHRs allow for such a method to be implemented through the use of quality reporting (as discussed previously). By switching the model, physicians theoretically should be more inclined to utilize their EHR capabilities which could lead to further educating their patients and stronger relationships being built between the provider and their patients. Furthermore, it would inspire continuous care to be implemented as physicians would be paid for keeping improving patient outcomes as opposed to how many times they can get their patients in their office for a visit.

Such methods that offer a pay-for- quality model are payment by capitation, bundle payment, or a mix of capitation and fee-for-service for specialty treatments. The capitation method would pay doctors for the number of patients they see per month regardless of what labs and procedures are conducted. This model has one big flaw in it however, as it does not incentivize physicians to be comprehensive with very ill patients that may cost the doctor more to treat. Bundle payment is along the same lines as capitation, except it pays the physicians a flat rate per month and doesn’t take into account the number of patients involved. This has the same flaw as capitation but also incentivizes physicians not to take on as many patients. Thus a mix of fee-for-service and capitation is believed to be, if not a possible solution, a good starting point for a pay-for-quality model. If such a model were to be in implemented into the American healthcare system the general population would theoretically be healthier as the physicians would be more inclined to prevent illness and increase patient outcomes.

CONCLUSIONHIT can improving community health outcomes through the use of EHRs, PHRs, and

HIEs to monitor conditions, provide education, improve quality, and possibly aid in reshaping the health care system. A majority of the people who use healthcare services are those who have chronic conditions. It is believed that EHRs, with their ability to store patient information and generate reports on patient and population alike, may hold the key to better treatment of these patients. Coupling this idea with an interoperable PHR, the quality of care improves dramatically as the patient becomes more involved in working with their physician to improve their own outcomes. However, to have this idea work the model in which healthcare providers are reimbursed must change. Currently, misaligned incentives are persuading physicians not be as thorough with their patients, as seen in the fee-for service model. In order to maximize the potential of HIT, the model must be switched to one that focuses on improving patient outcomes versus treatment of current symptoms. The process of making such changes will take time but it is believed that it can be achieved as other countries have already made the switch. The future poses many challenges, but change is essential as America continues to spend so much and produce so little.

REFERENCES

1) Lorenzi N. M., Kouroubali A., Detmer D.E. and Bloomrosen M. (2009). How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings. BMC Medical Informatics and Decision Making 9:15.

2) Hillestad R., Bigelow J., Bower A. Giorosi F., Meili R., Scoville R. and Taylor R.(2005) Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs. Health Affairs 24(5). 1103-1118.

3) Crow, B., Fulfrost,B., et tal., (2005) Health Care Spending. UC Atlas of Global Inequality. UC Santa Cruz. http://ucatlas.ucsc.edu/spend.php (Accessed 7/11/2010)

4) Tang, P. C., Ash, J. S., Bates, D. W., Overhage, J. M., & Sands, D. Z. (2006). Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption. J Am Med Inform Assoc, 13(2), 121-126.