Rational application of Health Information Technology will be one of our saving graces in our future as physicians. Now more than ever, it is crucial for us to embrace the process of collecting data to show the value of what we do.
That said, physicians face a number of challenges adapting to the changes accompanying the transformation of healthcare that are occurring at an increasing pace. Securing patient referrals and payment for services requires the development of new approaches to clinical practice. These include population health management caring for populations of patients, incorporating disease management approaches to care over the course of disease process and providing value based healthcare, demonstrating the benefit of care on overall quality of life and wellbeing of the populations served.
Evolution of HIT Needs
These emerging models of care require workflow redesign and change management. HIT will increasingly play a role in providing foundational support to enable workflow and process changes that will foster stronger relationships and healthcare experiences. These technologies will ultimately provide tools to assist clinicians and patients in managing medical conditions and related psychosocial problems more effectively. There will be an emphasis on improving patients' functional health status and enhancing coordination of care as well as eliminating duplication of services, and reducing the need for expensive medical services that do not add value.
An important component of this will include measuring clinical outcomes to provide a way to demonstrate the effectiveness and quality of care. This can empower practitioners to have a way to contribute to clinical effectiveness research using the voices of their own patients as well as serving as a basis for advocacy on behalf of their patients and practices.
The government has mandated that electronic health records begin to address these issues in the migration towards Meaningful Use 2. Improving communications with patients, encouraging patients to take ownership and manage their health and healthcare requires that clinical summaries of their health outcomes be available (HealthIT.gov). Over time decision support elements will become integrated into the EHR.
Physician Challenges and Frustrations
Physicians are acutely aware of these issues and challenges. In a recent survey of independent specialty physicians jointly sponsored by ProCare Systems and Becker's Healthcare:
• 71 percent of physicians envision that their practices will be significantly impacted by disease management and whole person care.
• 86 percent anticipate that reimbursement from payers will be driven by clinical outcome data demonstrating the quality and value of care.
• 80 percent of physicians feel that changes in the healthcare regulatory, compliance and government policy landscape affect their future as an independent physician
Adding to this sense of uncertainty and frustration is the fact that to date the implementation of EHRs into medical practices has not lived up to the expectations or needs of practicing physicians. A recent survey from the Rand Corporation and the American Medical Association found that hassles with EHRs were one of the top two areas of dissatisfaction among doctors. The other leading source of frustration was the amount of bureaucratic and regulatory obstacles which, according to doctors, impeded the quality of patient care.
Many physicians reported that the current use of EHRs actually detracted from patient care. Dr. Jay Crosson, vice president of professional satisfaction of the American Medical Association and a co-author of the Rand report acknowledged that: “One of the highest correlations with satisfaction was whether the physician felt he had adequate time with the patient; time to counsel on lifestyle, or talk about preventive screenings. Everything that detracts from that time is a dissatisfier.”
To make matters worse, dissatisfaction with the current use of EHRs is actually increasing. In another survey, the American College of Physicians and American EHR Partners of March 5, 2013 indicated that satisfaction and usability ratings for certified electronic EHRs have decreased since 2010 among clinicians across a range of indicators. Overall, user satisfaction fell 12 percent from 2010 to 2012. Users who are “very dissatisfied” increased 10 percent during the same time period. These findings highlight the need for the Meaningful Use program and EHR manufacturers to focus on improving EHR features and usability. One of the ways to accomplish that is to have practicing physicians become more involved in creating software that meets their real world needs.
Shaping Technology to Meet Physicians' Needs
An example of such software is the PRISM™ patient management system that has been designed by practicing pain medicine physicians at ProCare Systems to assist them in caring for their patients. Drs. Fred Davis and Mark Gostine recognized the need to capture clinical outcomes data from their patients in the late 1990s. Over the ensuing years they developed a patient reported self-assessment tool called the Pain Health Assessment that is completed by patients using an iPad or through the patient portal of their practice.
The next challenge was to gather the data, analyze it and put it into a format that can be used to help educate the patient and inform clinical decision making. The result was the Patient Summary Page; a dashboard providing real-time information reflecting psychosocial, functional, quality of life measures and patient satisfaction. This page summarizes components of the patients' pain experience that are not evident on other studies such as an MRI and provides physicians with a comprehensive clinical picture of how pain is affecting their patients' lives.
Additional components including an overall disease burden score and narcotic risk assessment have been incorporated to provide physicians with additional information that can assist in care management. As the system evolved, clinical performance and enterprise reporting functions were added which allow for the collected medical intelligence to be used to drive the business performance of the practice.
Customizing Pain Treatment with PRISM™
Integrating the PRISM™ system into the EHR has given the pain medicine physicians in the ProCare network a home grown toolbox which has been accepted by the patients and clinicians. Dr. Kevin Fitzgerald and Dr. Bindu Popat-Lewis from Michigan Pain Consultants who use the system were recently interviewed regarding their use of the PRISM™ system.
"This tool makes our conversations with patients so much more effective," reports Dr. Fitzgerald. "Often, patients can't explain their pain and say they 'just hurt.' On the other end of the spectrum, patients who are doing remarkably well with pain symptoms still aren't functioning well in their daily life. PRISM™ allows patients to articulate the essence of their pain – both physical and emotional – which in turn allows us to have a meaningful dialogue about the overall improvement in their quality of life. It's unique in measuring the nuanced factors that indicate improvement to me, but may not be immediately apparent to the patient.
"For example, PRISM's™ various measurement factors may tell me that a patient's overall function and depression levels have improved from his last visit – so even though he doesn't think the physical pain is improving on the surface, I can explain precisely how he's doing better through the change in quality of life indices. Simply gauging a patient's physical pain is not an effective or comprehensive way of gauging their improvement. And it means a lot to patients when you can show them the improvements they're making.
"PRISM™ also helps our physicians explain the day-to-day impact of chronic pain on their patients' lives. We can refer back to the answers in a patient's latest questionnaire and say, 'The pain has robbed you of who you normally are and impacted your ability to do the things that make you happy. If we can get rid of it, we'll see the real you again.' We're effectively coaching our patients and have seen constant improvement in their pain levels as a result of this approach."
Dr. Popat-Lewis commented: "The system is designed to make a patient feel as comfortable as possible when answering tough questions about their pain level and their emotional state. We give each patient time to take the questionnaire in a reflective and relaxed state, and this leads them to communicate subtleties about their psychological, emotional and physical feelings that may not be candidly expressed in a face-to-face discussion with a physician."
Dr. Fitzgerald added: "The key also lies in the type of data that's extracted. Pain is so subjective, and it's vital to treat patients in a way that goes beyond merely gauging the physical feeling – we need to also target the psychosocial levels. Prior to PRISM™, there was no consistent method for measuring this, despite the fact that this information is critical for treating patients effectively.”
The acceptance of the PRISM™ system by the clinicians that use it is critical and fulfils many of the goals for advanced use of HIT. The key for any software developer is to work directly with practicing physicians and practices. Dissatisfaction with HIT can be mitigated if programs are designed that actually improve the day to day practice by the users.