“The widespread adoption of electronic health records (EHRs) during the past decade has been hailed as a major advance in medical practice. Recently, however, a growing number of clinicians have spoken out about the counterproductive effects of these systems on patient care. The national push toward greater implementation of EHRs was inspired by accumulating evidence that promised improvements in care coordination, quality, safety, and patient engagement. What has gone wrong?
The answer is, of course, multifaceted, but largely ignored in the discussion has been the effect of the underlying mode of physician payment. Payment at the clinician level remains predominantly fee for service, increasingly supplemented by pay for performance in an effort to increase value-based reimbursement. Both modes of payment are largely process-based and retrospective. EHRs are ideally suited for such process-based reimbursement since they provide detailed, piecemeal, readily audited documentation of process and volume. The more detailed the documentation of process, the greater the opportunity for reimbursement.
An electronic arms race has broken out as payers demand increasingly detailed documentation to justify payment and EHR vendors respond with ever more elaborate documentation tools — with payers and provider organizations spending billions of dollars in the process. Much to the chagrin of clinicians, the EHR has become a billing instrument that requires excessive process documentation, coding, and other activities that are devoid of meaning for patient care …
A host of short-term solutions have been implemented to ease physicians’ documentation-related workload, … [However it] is ironic that process documentation and fee-for-service payment prevail at a time when process-based performance has been shown not to positively affect important health outcomes and when paying for value rather than volume has become a policy mandate.
Delivery from EHR purgatory may require a fundamental change in the way we pay clinicians: moving from rewarding processes to rewarding outcomes. Such a shift puts patients’ and society’s goals front and center, redirecting the work of physicians in a professionally meaningful and socially responsible manner. The patient’s care experience, functional status, and quality of life, as well as the degree of personalization of care and resource stewardship, become the central parameters for performance measurement …
The implications for EHR use and the clinical encounter are considerable. A focus on outcomes places renewed emphasis on eliciting and recording essential elements of care, such as the patient’s story, perspective, health status, risk factors, and important physical findings and test results. Attention to these details can help physicians formulate a differential diagnosis and customized care plan, taking into account patient preferences, values, and goals. Having the time to adequately address these elements of clinical care instead of checking off boxes, pasting boilerplate entries, and searching for codes designating diagnoses and procedures with the highest reimbursement rates presents an opportunity for restoring precision and meaning to the medical record. Clinician entries could be complemented by a patient-generated functional status report and set of personal care goals. Such an EHR would begin to take on the look and feel of an essential instrument of patient care and population health management rather than a billing statement …
Delivery from EHR purgatory is within our reach if we as a profession have the will to take more responsibility for outcomes. Not all outcomes are under our control, but focusing on those we can reasonably affect represents a genuine opportunity to restore meaning to our daily work and the social contract we have with our patients and society.”
The foregoing excerpts from the Perspective article by Allan H. Goroll, M.D., entitled Emerging from EHR Purgatory — Moving from Process to Outcomes in the May 25, 2017, issue of New England Journal of Medicine (http://bit.ly/2qGx5lS) highlight shortcomings of current electronic health/medical record (EMS/EHR) commercial off the shelf (COTS) information technology (IT) systems for medical practice and healthcare delivery improvement. However, as Dr. Goroll observes, “A focus on outcomes places renewed emphasis on eliciting and recording essential elements of care, such as the patient’s story, perspective, health status, risk factors, and important physical findings and test results. Attention to these details can help physicians formulate a differential diagnosis and customized care plan, taking into account patient preferences, values, and goals.” An IT approach compliant with the Cloud Healthcare Appliance Real-Time Solution as a Service (CHARTSaaS) integrated development environment (IDE) reference architecture (RA) can facilitate the back-to-basics refocusing of organizational and professional healthcare providers on outcome-based care.
A CHARTSaaS RA-compliant IT solution can enable healthcare provider subject matter experts (SMEs) to design, develop, deploy and operate applications a.k.a. apps that leverage installed EHR/EMR systems to implement automated cognitive support including the following capabilities, accessible for a low and expensed cost (i.e. — monthly and usage-sensitive subscription) and usable with minimal IT SME assistance (by employing drag-and-drop, formatted text entry, table completion and other techniques not requiring computer coding capabilities):
- Analytics — Select from available list or create new artifact of Bayesian multi-variate analyses for similarity and predictive purposes;
- Automation — Select from available list [of CHARTSaaS-created artifacts] launch/terminate operation with/without edit of run-time conditions;
- Casefiles — Select from available list or create new artifact and edit/delete source database/dataset pathway/location and record subset definition [including location of and policies for use of publicly accessible evidence-based medical records a.k.a. charts that are the patient-identifiable responsibility of the CHARTSaaS Subscriber/user and/or the de-identified public records managed by such organizational custodians of CDC, CMS and WHO];
- Collaboration — Select from available list or create new artifact [including authorized collaborator users] and edit/delete social media to be incorporated (e.g. – Facebook, Twitter, LinkedIn);
- Events-Things — Select from available list or create new artifact and edit/delete source/device, parameter(s) to be managed, data thresholds/limits, time durations and/or dates/times of occurrence;
- Information — Select from available list or create new artifact and edit/delete source locations/pathways, extract/transform/load parameter values and destination locations [for typically narrative and/or unstructured data from any Internet-accessible source];
- Interoperability — Select from available list or create new connectivity and/or communication artifact [including legacy/installed EHR/EMR and other ancillary/departmental systems/applications] and edit/delete connection end points and transport parameter values, including data formatting and encryption;
- Mobility — Select from available list or create new artifact and edit/delete form factor [desk-top, laptop, tablet or phone (Android or iOS)], operating system and/or other parameters needed for automated code download and conversion for destination device;
- Modeling — Select from available list or create new artifact and edit/delete swim-lane flowchart description [implemented using Microsoft Visio and to be convertible to run-time code with a one-click software button invoking Object Management Group (OMG) Business Process Management Notation (BPMN)];
- Monitoring — Select from available list or create new artifact and edit/delete business activity monitoring tool name and location and configuration data values a.k.a. key performance indicators (KPIs) [functionality typical of COTS business activity monitoring (BAM) solution];
- Optimization — Select from available list or create new artifact and edit/delete version management data and comparative effectiveness data; and
- Decision-making — Select from available list or create new artifact and edit/delete Boolean decision management parameter data in decision table [implemented using Microsoft Excel and to be convertible to run-time code with a one-click software button invoking Object Management Group (OMG) Decision Management Notation (DMN)] and/or If…Then…Else format and locations of subject data for evaluation/testing.
Please validate to your own satisfaction the proposition that a CHARTSaaS RA-compliant IT solution can facilitate the migration from process- to outcome-based care and treatment advocated by Dr. Goroll by reading the white paper at http://bit.ly/2r1OtoR and then by reviewing the details of CHARTSaaS and the CHARTSaaS RA in these presentations:
Healthcare providers will benefit significantly from appreciating and then applying a CHARTSaaS RA-compliant IT solution. To do so will mitigate medical mistakes (currently the third leading cause of patient deaths. per Makaray and Daniel (re http://bit.ly/1rtW6Sa); thereby minimizing patient adverse events and optimizing clinical case outcomes while maximizing the cost-effectiveness of care and treatment, and also accelerating the accrual and facilitating the application of medical knowledge.