Many believed the electronic health record (EHR) would be the panacea to managing patient medical information. While these systems have many merits, the extent of data sharing capability necessary to ensure continuity of care isn't among them. In fact, EHRs were never designed with interoperability in mind. So, what is the next step that needs taken to be sure patients' care is coordinated, compliant and effective?
I was involved in a conversation the other day about how well electronic health records (EHRs) can help solve the care coordination crisis we are struggling with across the country.
The premise suggested by others went something like this:
"Once every hospital and every physician office has an EHR in place, care will be very easy to coordinate. There will be interoperability, whether mandated by the federal government or not, and at the very least, some form of Continuity of Care Document (CCD) will be able to easily float from provider to provider through a cloud-based structure."
Suggestions were made that everyone would put their data in this common cloud, if not for ease of sharing, then at least because it lent itself to providing superior care. The only thing missing was the last paragraph of the sermon from the church of the EHR suggesting that electronic medical records systems would save the world from destruction.
Obviously, I didn’t agree. Don’t hear me wrong; it would help, but after we get over the ubiquitous concerns about patient privacy, the runway needed to truly achieve interoperability (remember, this isn’t just Epic, Cerner, and Allscripts talking to each other – how many ambulatory systems are there? HIE’s?), and changes needed in practice processes to make this feasible, it will be years (maybe even decades) from now.
And that’s not the biggest issue. The biggest issue, in my opinion, is the need for community-based services and non-medical caregivers to provide patient oversight in a manner that is coordinated, compliant and effective. Today, you can’t (and no hospital compliance officer would let you) give a non-medical community provider access to a patient’s EHR. In fact, if they are not directly subcontracted with the hospital, it would be a clear violation of HIPAA (and, even if they were, you’re walking a very, very thin line). So, the EHR space leaves a whole set of provider classes out of the mix when it comes to caring for patients. You have two systems: the clinical, EHR-based providers who are deemed worthy by HIPAA to view a patient’s record for the purposes of providing care; and the community-based, in-home workers who provide companionship, housework, meal preparation, transportation, and other services critical to well being which are given little to no means for collaborating with the other system. And there’s the rub. Ask a payer. They’ll tell you that, if the patient is progressing toward their health goals, then the simpler, home-based and less expensive support option is better.
So how do we unify the systems? One hard piece to the puzzle is the need to re-look at HIPAA and how privacy is handled. But a larger, easier solution can be achieved by realizing that the electronic health record is not the best method to handle ALL of a patient’s care information. Yes, it serves its purpose – and does so quite well. The vendors have brought significant value to the market; but, there is so much more that can be done before we ever consider how they expand beyond the clinical world where they exist today. And HIEs have just become an EHR-sharing mechanism fraught with the myriad data in a clinical system.
The solution will likely come from a disruptive source outside what’s believed to be the mainstream market. What the solution needs to do is connect patients, families and caregivers (medical and non-medical) in a way that facilitates high-level information about the patient’s condition being shared across engaged, yet disparate parties. So instead of needing to measure and push a patient’s sodium levels across the channels every day, let’s take a step back and focus on the patient. What support do they really need? How are they feeling? Yes, we’ll get to some basic clinical data like medication compliance and blood pressure, but for the most part we want to know that the patient ate, moved, was mentally alert and interacted. These aren’t in an EHR or recorded by a medical provider, yet they are key indicators of the patient’s place on a path toward continued wellbeing.
I’d like to propose that we take a step back as an industry and focus on the whole patient. We’ve known for a long time that a patient is more than a set of clinical numbers. It’s time we realize that we can’t coordinate care for the patient from that perspective, either. It’s time to invest in building integrative systems to manage the problems and issues of the whole person.