Health Tracking From the Field Transforming Care: Medical Practice Design And Information Technology How one innovative medical practice has eliminated many office visits and improved continuity of care for patients with chronic conditions. by Charles M. Kilo ABSTRACT: The transformation of the medical practice is possible today because of the advancement of system design knowledge coupled with innovations in information technology (IT). Examples of such transformed care are present today, and they are creating a roadmap for others. Those efforts are also elucidating critical issues in the use of IT to advance health care quality. Connectivity, electronic integration, and knowledge management are the key functionalities emerging as levers to promote this transformation. Fifty percent of ambulatory care visits are unnecessary. This statement might garner some attention. Some view it with skepticism and resistance, demanding data to justify the claim. Others simply consider it absurd. The reasons for this reaction are multiple, but they are largely driven by a pervasive mindset that automatically equates visits with care. Note that I do not claim that the care being delivered is unnecessary, but simply that the visit as a mechanism of care is unnecessary. Over the past fifty years, while the environment of care has changed dramatically with the development of new clinical knowledge, diagnostic and treatment technologies, and pharmaceuticals, the clinical office has been remarkably stable in structure and function. The physical layout, the exam room, the scheduling system, and visits as the mechanism of care are all virtually unchanged. The deficiencies of current ambulatory care systemsandtheimperativetomovetoward higher performance are well documented. 1 Fortunately, for the first time in history, we now possess both the knowledge and the technology to fundamentally transform the medical practice. 2 If these capabilities are rigorously applied, the coming decade will see remarkable changes in care delivery. This paper discusses aspects of the transformative changes under way in ambulatory care from an information technology (IT) perspective, using examples from GreenField Health in Portland, Oregon. GreenField Health was established in 2001 based on a foundation of knowledge established by the Institute for Healthcare Improvement, the Robert Wood Johnson Foundation s Institute for Chronic Illness Care, and others. It is an independent clinic with four internists and one adolescent medicine specialist. It also serves as a research and development laboratory for ambulatory system design. We actively explore the use of IT and system design to understand how they can be better applied to improve care. An example. Malcolm is a healthy fortysix-year-old male who was noted to have high blood pressure on periodic screening in March Chuck Kilo (chuck.kilo@greenfieldhealth.com) is a fellow at the Institute for Healthcare Improvement and chief executive officer of GreenField Health in Portland, Oregon. 1296 September/October 2005 DOI 10.1377/hlthaff.24.5.1296 2005 Project HOPE The People-to-People Health Foundation, Inc.
From the Field 2005. He was seen as a new patient for hypertension management. Malcolm s past medical history and physical exam were remarkable for a blood pressure of 165/100 and a possible midsystolic click followed by a murmur suggestive of mitral value prolapse. As is routine for new patients, Malcolm had a cardiac risk assessment based on the National Cholesterol Education Program guidelines using a tool built into our electronic health record (EHR). This assessment took approximately one minute to complete while simultaneously providing an explanation to Malcolm. Based on his age and diagnosis of hypertension, he fell into a moderate risk category for coronary artery disease, meaning that his LDL cholesterol target was less than 130 mg/dl. Malcolm had not had his cholesterol level checked in several years. Generic lisinopril, an effective antihypertensive, was started, and he was encouraged to purchase an automated blood pressure monitor. Instructions were given, including systolic and diastolic blood pressure targets and directions on the lisinopril dosage range that he could try, to achieve the targets. He was encouraged to test different doses within this range. Fasting lipids were ordered as well as echocardiogram to evaluate his heart. Malcolm left the initial visit without a scheduled follow-up visit. Instead, e-mail or phone follow-up was planned, and automated future reminders were placed in his EHR as prompts to review his blood pressure management. E-mail would be used to provide rapid feedback of test results, to answer questions, and to provide ongoing coaching about hypertension self-management. Because hypertension was coded on his problem list, he was also automatically placed into our electronic hypertension registry. If planned nonvisit follow-up should fail, our computer system would alert us a safety net for Malcolm. The lipid panel was performed at our local lab and fed directly back in an electronic format into our EHR. Using secure e-mail, those results were sent to Malcolm the next day with an explanation a twenty-four-hour turnaround time for laboratory results. Malcolm sldlwasbelowhistarget,sono specific treatment would be necessary. The echocardiogram was performed by a local private cardiology group, and the reading was also e-mailed directly to me (his physician) the following day. Upon reviewing the result, I forwarded it in its entirety to Malcolm via secure e-mail, simultaneously inquiring about his blood pressure management. Malcolm has not had a second clinic visit, nor is one scheduled. We have had several e-mail exchanges to continue his hypertension management, with each exchange documented in his EHR. Role of IT. Malcolm s care demonstrates the rapid evolution of ambulatory care. Such transformation requires both system design knowledge to give guidance on the construction of effective medical practices as well as the necessary IT to support redesigned clinical workflow. AtGreenFieldHealth,wehaveusedboth telephone and electronic contact extensively to explore how patient management might be more appropriately designed. Approximately 80percentofourpatientcontactsoccurvia phone and e-mail, with only 20 percent occurring in visits. Since visits require more time, this translates into approximately half of a clinician s time being dedicated to visits and half to phone and e-mail contact. Providing such care requires a stringent focus on quality and the patient s experience of care. It necessitates an IT infrastructure that provides rapid access to appropriate, patientspecific information; an e-connectivity infrastructure that integrates with EHRs; systems to assure adequate patient follow-up; and methods to track patients so that they do not become lost to follow-up. The technology necessary to transform the medical practice even a small medical practice is a complete, integrated, interoperable information system. GreenField Health s clinical information system contains the following components: (1) EHR; (2) practice management system; (3) customized encounter forms; (4) disease registries; (5) secure messaging (e-mail) and connectivity; (6) secure Internet portal for pa- HEALTH AFFAIRS ~ Vo l u m e 2 4, N u m b e r 5 1297
Health Tracking tients; (7) online clinical information; (8) practice decision support; (9) patient decision support; (10) electronic diagnostic technology; (11) scanning; (12) network faxing; (13) interfaces with laboratory, radiology, and hospital systems; (14) medical group intranet; (15) patient e-newsletter; and (16) telecommunication systems. These products reside on a network that includes an operating system, high-speed Internet access, voice recognition software, secure remote access, backup systems, antispam and antiviral software, word processing, spreadsheet, general ledger and accounting software, and more. Such a system must, by necessity, connect and integrate information from both within and outside of the practice, including the patient. Malcolm s care illustrates this connectivity. While Malcolm s needs were relatively straightforward, it is easy to see how such technology-enabled care can be applied to other patient populations. For example, people with chronic conditions can have a greater amount of contact with the practice using fewer visits when self-management training and support are coupled with direct practice connectivity and electronic systems. Appropriate lab studies can be ordered and the results communicated rapidly and directly to the patient along with self-management coaching without depending on visits and such care is possible with technology available today. It is not just the individual components of the system that produce higher-quality care. Rather, it is the way in which the components are connected to each other and integrated into the clinical workflow that matters. Disease registries further illustrate this point. Registries and tracking. A critical barrier to moving toward nonvisit care is that medical practices use their scheduling system as a follow-up system. They instruct patients to schedule return visits largely because visits are the only way practices are aware of their Time-pressured visits represent episodic care at a time when a large percentage of patients needs are continuous. patients. In a world less dependent on visits, tracking patients is of vital importance. The transformed practice must be aware of its patients continually, regardless of whether or not visits are scheduled. Not only are time-pressured visits a limiting way of interacting with patients, but they represent episodic care at a time when a large percentage of patients needs are continuous particularly for those with chronic conditions. A disease registry is a tracking system necessary for the optimal provision of chronic and preventive care. Registries generally draw their data from EHRs and present the data to clinicians. 3 They perform three functions: (1) Visit planning: they provide summarized, patient-specific reminders for chronic and preventive service needs at the time of a visit. (2) Proactive care: they identify patients who are due for services, independent of whether or not they have a visit scheduled. For example, they can identify all diabetics due for necessary blood tests. (3) Performance measurement: they provide aggregate, real-time data on performance. The power of this functionality cannot be overestimated. Using registries, practices can generate lists of patients due for specific services. For example, a registry will list diabetics who have not had a glycosylated hemoglobin test in the past six months, those with a glycosylated hemoglobin of greater than 7.0 mg/dl, those who are due for yearly retinal eye exams, and much more. Registries can also list, for example, patients on thyroid replacement who are due for appropriate monitoring and people in the high-risk category for cardiovascular disease, based on specific national guidelines, who are not at the recommended LDL cholesterol target. The implications of these data can be overwhelming. How should a practice with limited resources assure that these needs are being addressed? It is unrealistic to think that a practice can hand such registry-generated lists of 1298 September/October 2005
From the Field specific patient needs to physicians or others in the practice, expecting them to call each person for follow-up. The volume tends to outstrip the capacity. The solution to this problem brings us back to the topic of system design enabled with sophisticated technology. A 2004 California HealthCare Foundation review of registries concluded that a disease registry is only one component of a more comprehensive disease management strategy. To effectively manage chronic conditions and provide better care to patients, a registry must be integrated into a program that includes elements such as provider support, use of multidisciplinary provider teams, and increased patient self-management. A registry can enhance disease management of a population, but it is not a disease management program by itself. 4 Addressing the conundrum of providing registry-directed patient-specific follow-up is an area of active investigation. At GreenField, we believe that the solution again lies in IT system integration along with connectivity. We are working to merge our registry data, derived from our EHR, directly to a secure messaging system, so that patients are automatically informed of their care needs via e- mail, without the need for human intervention. These e-mail messages will not only inform patients of their prevention and screening needs, but they will also provide specific instructions on fulfilling those needs. Forexample,e-mailwillbegeneratedona regular basis to all diabetics summarizing their current prevention and screening data such as the date and result of their last glycosylated hemoglobin and the date of their last eye exam. Concordant with this, orders will be sent to the laboratory, and patients will be instructed to get the test done if necessary. They will also be given the opportunity to update oursystem,sincewemaynotbeawareoftheir last dilated diabetic eye exam, for example. Others are rapidly pursuing similar constructs using secure patient portals. Some will certainly be concerned that not all patients have access to e-mail. Although this is true, e-mail is a pervasive form of communication, and its use is increasing rapidly, even among the elderly and people in lower socioeconomic strata. Such tools do not spell a solution for all patients or all conditions, but in our experience, they do apply to a very large percentage of patients. Knowledge management. Malcolm s care demonstrates another valuable aspect of available information technology: the capabilities of knowledge management. Knowledge management tools take many forms and fulfill various functions. Cardiovascular risk management provides an effective example of how such simple tools can provide important clinical benefits. National recommendations are for all adults to be risk-stratified to determine their cardiovascular risk, with cholesterol management based on this risk classification. 5 People at high, moderate, and low risk have different LDL cholesterol targets, which guide the aggressiveness of lipid management efforts. Although some practices accomplish this with individual patients, very few have all of their patients risk-stratified with a measurement system that allows them to know their specific performance against each risk category for example, the percentage of high-risk patients who are not at the LDL target, and which specific patients are not at the target. In the absence of such risk-stratification and population-monitoring capabilities, many low-risk patients receive treatment when it is not indicated, and many high-risk patients remain undertreated. Within our EHR, we use a simple risk stratification program. 6 This program automates the National Heart, Lung, and Blood Institute s National Cholesterol Education Program s risk classification. Each new patient undergoes a risk stratification that is updated periodically. Lipids are managedtospecifictargetsbasedoneachperson s risk category. Each patient s risk category is listed on his or her electronic problem list, which makes it possible to monitor our overall performance. Such measurement also requires each patient s lipid results to be electronically filed in the EHR s database. This is difficult to accomplish if lab results are reported back to HEALTH AFFAIRS ~ Vo l u m e 2 4, N u m b e r 5 1299
Health Tracking the practice on paper in those cases, detailed performance measurement requires the manual input of data into the EHR, which is a time-consuming task. At GreenField Health, we accomplish this by having our lab results delivered to our system electronically in an appropriate format, so that they automatically flow into the EHR s database. This requires an electronic interface with a lab vendor and a reconciliation process to assure that the lab results are flowing into the appropriate patient record. The morbidity of cardiovascular disease and the expense of commonly used lipidlowering medications necessitate the provision of reliable preventive services. Simple tools integrated into the information system make the promise of reliable care a reality. IT challenges. Two IT challenges are worth noting. The first is connectivity between practices to allow for rapid coordination of care and sharing of information. Within integrated multispecialty groups, a common IT infrastructure allows all provides instant access to patients information, direct electronic communication and feedback between clinicians, and much more. IntheworldofprivatepracticeinwhichI work, achieving virtual integration across independent medical groups is a more difficult challenge. However, technology companies are now providing connectivity tools that allow rapid sharing of information across platforms, products, and organizations, resulting in more efficient coordination of services between practices. The continued development of such tools will help accomplish virtual integration across independent practices and organizations. For example, several specialty colleagues are available to my practice via e-mail to address clinical questions, and several of them provide rapid electronic feedback following consults. This occurs by the transmission of consult notes, radiology results, and procedure results directly to us via secure messaging, generally within twenty-four hours after the serviceisperformed.thisallowsmuchmore timely coordination of care. Other efforts to facilitate connectivity on a much larger scale include the creation of data standards and the rapidly growing interest in regional health information organizations (RHIOs). The second challenge is the development of more advanced knowledge-management tools. Although bits and pieces of knowledge management are available in some EHRs, truly advanced capabilities have lagged in development. Technology companies working on this complicated challenge do exist, but products remain in their early stages of development. Knowledge management, not electronic record keeping, should become the primary capability of our electronic systems. Most EHRs available today are focused primarily on creating a record and documenting compliance with evaluation and management standards for billing purposes. Although these are important functions, they should in fact be secondary to clinical knowledge management. The development of true knowledgemanagement tools will likely lag for some years, since the health care marketplace is not yet ready for such advanced products and since funding sources namely venture capitalists are generally skeptical of health care IT because of their adverse experiences in this sector in recent years. Policy challenges. Although it is not my intent to discuss policy in depth, a few issues are worth noting. First, the finance system should align itself with advanced methodologies of care. The experience at GreenField Health is evidence that much care can be delivered without resource-intensive office visits when phone, e-mail, group medical appointments, and other methods are supported by theappropriateitinfrastructureandsystem design. The question is how to appropriately remunerate such services. Pay-for-performance and pay-for-e-mail initiatives are a worthy start. Laudable as these efforts are, however, I believe that payment innovation should be more tightly coupled with efforts to truly transform care, to accelerate that work. A second issue pertains to the verification of outcomes and sustainability of transformed practices. Although the availability of perfor- 1300 September/October 2005
From the Field mance data is growing, independent verification is needed. This will require investigative methodologies robust to multiple simultaneously changing interventions. Traditional research methodologies will have difficulty discriminating the effect of any one change during this time of rapid innovation. Researchers will be challenged to understand which of the many changes under way are responsible for the changes in performance. Conclusions. Intheirpaperaboutthe use of EHRs, Robert Miller and Ida Sim observe that the [EHR] is an enabling technology for physician practices to pursue quality improvement in potentially powerful ways. Our research finds, however, that systematic quality improvement using [EHRs] is neither low-cost nor easy. There is no simple solution to accelerating [EHR] adoption and use for quality improvement. 7 The ability to improve quality is dependent on using the right technology and using it the right way. Integration, connectivity, and the incorporation of IT into intelligent system design will be critical to the large-scale success of performance improvement efforts. Although it is easy to point to the payment system as the root cause of our current situation, and although we should be pushing for major changes in financing, particularly for primary care, it is critical that financing changes be thoughtfully designed, based on well-vetted data on the design and performance of transformed systems. It is shortsighted for clinicians to point to the financing system and state, I ll change when you change first. The job is ours: to define new approaches to care, to collect supportive data, and to then work with our health care financing colleagues to support the rational delivery of care. NOTES 1. See, for example, Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twentyfirst Century (Washington: National Academies Press, 2001); E.A. McGlynn et al., The Quality of Health Care Delivered to Adults in the United States, New England Journal of Medicine 348, no. 26 (2003): 2635 2645; and M.R. Goulding, Inappropriate Medication Prescribing for Elderly Ambulatory Care Patients, Archives of Internal Medicine 164, no. 3 (2004): 305 312. 2. See, for example, Institute for Healthcare Improvement, Office Practices, www.ihi.org/ihi/ Topics/OfficePractices (2 May 2005); Proceedings from the Institute for Healthcare Improvement s Sixth Annual International Summit on Redesigning the Clinical Office Practice, Washington, D.C., 30 March 1 April 2005, www.ihi.org/ihi/programs/conferencesandtraining/ 6thAnnualOfficePracticesSummit.htm (2 May 2005); and C.M. Kilo and M. Leavitt, eds., Transforming Care using Information Technology (Chicago: Health Information Management and Systems Society, 2005). 3. J. Metzger, Using Computerized Registries in Chronic Disease Care, February 2004, www.chcf.org/documents/ chronicdisease/computerizedregistriesinchronic Disease.pdf (2 May 2005). 4. J. Simon and M. Powers, Chronic Disease Registries: A Product Review, May 2004, www.chcf.org/documents/ chronicdisease/chronicdiseaseregistryreview.pdf (2 May 2005). 5. More information about the National Heart, Lung, and Blood Institute s National Cholesterol Education Program (NCEP) is available at www.nhlbi.nih.gov/about/ncep (2 May 2005). 6. See an example of this at content.healthaffairs.org/cgi/content/full/24/5/1296/dc1. 7. R.H. Miller and I. Sim, Physicians Use of Electronic Medical Records: Barriers and Solutions, Health Affairs 23, no. 2 (2004): 116 126. The author thanks the physicians and staff of GreenField Health for their persistent pioneering efforts, Don Berwick and colleagues at the Institute for Healthcare Improvement, Ed Wagner and colleagues at the Improving Chronic Illness Care Initiative, and John Wasson for his ongoing guidance. HEALTH AFFAIRS ~ Vo l u m e 2 4, N u m b e r 5 1301