The critics are again piling on.
In the early days of EMRs, the pioneers like Intermountain, Vanderbilt, Duke, and Partners differentiated themselves by developing their own proprietary EMRs and then using them in a meaningful way, without any financial incentive except their own to do so. Meaningful Use Stage 1 served a valuable purpose; it jump-started the adoption of commercially supported EMRs in an industry that needed jump-starting. Maybe we should cancel Stage 2 and Stage 3, spend some of that money to seed true innovation (think DARPA for healthcare IT), and let survival of the fittest play a role in deciding which organizations will utilize their EMRs, and subsequent data, most effectively to improve healthcare.
From
"Is It Time To Eliminate Meaningful Use?"
"Spend some of that money to seed true innovation"?
Seriously?
What money? In case you've not been
paying attention, the bulk of the MU money has already been dispensed,
with the largest proportion of the relatively little that remains
earmarked for late-adopting Stage 1 participants. You're not going to
"seed" anything of substance on a national scale with remaining MU
funds.
Do people even
listen to what they're saying?
OUTCOMES MEASURES, ANYONE?
Process measures like Meaningful Use,
CQMs, PQRS, etc, as I've noted before, are tangential
proxies
for effectiveness in health care. It's assumed that if you are doing
and reporting on X, Y, Z, A, B, C, D, E, and F, improved outcomes will
eventually follow.
How about if we lay on a concerted effort to measure
actual outcomes directly? And, in that regard, a1c (the gamut of lab results, actually), BP, BMI, etc are themselves still
proxies, not "outcomes" in terms of end-results health.
Virtually
every dx of a suboptimal medical/health condition
has an associated prognosis and tx plan (the "P" component of the
"SOAP") aimed at improved outcome/resolution (even if it's sadly limited
to the palliative for the fatal dx's). We should be mapping realistic
interim and end-state "outcomes" goals to
every dx. Some will be
simple, others maddeningly complex and often problematic. But, without
them, we will simply continue to argue endlessly and fruitlessly about
health care effectiveness and "value."
Time to seriously get off the dime.
AHRQ website, on "outcomes" -
What is outcomes research?
Outcomes
research seeks to understand the end results of particular health care
practices and interventions. End results include effects that people
experience and care about, such as change in the ability to function. In
particular, for individuals with chronic conditions—where cure is not
always possible—end results include quality of life as well as
mortality. By linking the care people get to the outcomes they
experience, outcomes research has become the key to developing better
ways to monitor and improve the quality of care. Supporting improvements
in health outcomes is a strategic goal of the Agency for Healthcare
Research and Quality (AHRQ, formerly the Agency for Health Care Policy
and Research).
The urgent need for outcomes research was
highlighted in the early 1980s, when researchers discovered that
"geography is destiny." Time and again, studies documented that medical
practices as commonplace as hysterectomy and hernia repair were
performed much more frequently in some areas than in others, even when
there were no differences in the underlying rates of disease.
Furthermore, there was often no information about the end results for
the patients who received a particular procedure, and few comparative
studies to show which interventions were most effective. These findings
challenged researchers, clinicians, and health systems leaders to
develop new tools to assess the impact of health care services...
Measuring Outcomes
Historically,
clinicians have relied primarily on traditional biomedical measures,
such as the results of laboratory tests, to determine whether a health
intervention is necessary and whether it is successful. Researchers have
discovered, however, that when they use only these measures, they miss
many of the outcomes that matter most to patients. Hence, outcomes
research also measures how people function and their experiences with
care...
Future Directions
No
longer just the domain of a small cadre of researchers, outcomes
research has altered the culture of clinical practice and health care
research by changing how we assess the end results of health care
services. In doing so, it has provided the foundation for measuring the
quality of care. The results of AHRQ outcomes research are becoming part
of the "report cards" that purchasers and consumers can use to assess
the quality of care in health plans. For public programs such as
Medicaid and Medicare, outcomes research provides policymakers with the
tools to monitor and improve quality both in traditional settings and
under managed care. Outcomes research is the key to knowing not only
what quality of care we can achieve, but how we can achieve it.
OK. In the same vein, how about this, from
Academy Health,
HEALTH OUTCOMES RESEARCH: A PRIMER (pdf):
What is outcomes research?
Outcomes
research studies the end results of medical care – the effect of the
health care process on the health and well-being of patients and
populations. It spans a broad spectrum of issues from studies
evaluating the effectiveness of a particular medical or surgical
procedure to examinations of the impact of insurance status or
reimbursement policies on the outcomes of care. It also ranges from the
development and use of tools to measure health status to analyses of the
best way to disseminate the results of outcomes research to physicians
or consumers to encourage behavior change.
The
field of outcomes research emerged from a growing concern about which
medical treatments work best and for whom. In large part because of its
potential to address the interrelated issues of cost and quality of
health care, public and private sector interest in outcomes research has
grown dramatically in the past several years...
The Setting It Studies
Outcomes
research evaluates the results of the health care process in the
real-life world of the doctor’s office, hospital, health clinic and even
the home. This contrasts with traditional randomized controlled
studies, funded mainly through the National Institutes of Health, which
test the success of treatments in controlled environments. These are
called efficacy studies. Research in real-life settings is called
effectiveness research.
The Health Status Measures It Uses
Traditionally,
studies have measured health status, or health outcomes, in terms of
physiological measurements – through laboratory test results,
complication rates (e.g. infections) or death. These measures alone do
not adequately capture health status. A patient’s functional status,
well-being, and satisfaction with care must compliment the traditional
measures...
That was published in
1994,
twenty years ago. What are we waiting for? While I don't underestimate
the difficulties involved with establishing standardized "operational
definitions" of outcome measures, it is not impossible. Surely adding
uniform, basic quantitative progress/outcomes metrics to the "Active dx"
lists now a requisite staple of certified EHRs is do-able.
"Innovation," anyone?
THE CLINICAL PROCESS AND "PDSA"
We refer to the "SOAP" process, documented in the "SOAP note" now firmly in the center of the EHR.
- Subjective;
- Objective;
- Assessment;
- Plan.
The
subjective and objective data (including those comprising the relevant
aspects of FH, SH, PMH, Active Rx, Active dx, HPI, ROS, Vitals, Labs, PE) converge to underpin the physician's
"assessment" (dx) and resultant "plan" (Rx/tx/px) for mitigating (or
curing) the patient's current problem(s) and arriving at better health (the desired "outcome" from the patient POV).
As
my HealthInsight Sup Keith Parker (an astute, Harley-riding former
Special Forces medic) always liked to admonish, there should be an
explicit "E" (evaluation) at the end of the traditional SOAP model. My
quickie Photoshop visualization of the process cycle:
In terms of the PDSA improvement model,
S,
O, and
A of "SOAPE" comprise the planning phase (you plan based on the analytic aggregation and synthesis of your current data), the "Plan" (
P) is the "Do" phase, the "Study" is the "
E" of SOAPE, and, -- most often -- recursively, we subsequently revisit the "
A" (assessment" phase) of SOAPE. Did we hit the mark or not? If not, what next?
Fundamental to experimental science broadly is the
explicit
statement of the empirical (quantitated) goal in the planning phase,
answering the question "what will constitute a 'significant' improvement
vis a vis the
status quo?" You don't get to run an experiment and
then arbitrarily decide whether you've "improved" things or not.
Maybe that's "the
'art' of medicine," but it's not science.
4/28 UPDATE
Doctors Should Be Paid for Outcomes. But Which Outcomes?
By HANS DUVEFELT, MD
Should we be paid for outcomes?
This
is often proposed, but I have trouble understanding it. Real outcomes
are not blood pressure or blood sugar numbers; they are deaths, strokes,
heart attacks, amputations, hospital-acquired infections and the like.
In today’s medicine-as-manufacturing paradigm, such events are seen as preventable and punishable.
Ironically,
the U.S. insurance industry has no trouble recognizing “Acts of God” or
“force majeure” as events beyond human control in spheres other than
healthcare.
There
is too little discussion about patients’ free choice or responsibility.
Both in medical malpractice cases and in the healthcare debate, it
appears that it is the doctor’s fault if the patient doesn’t get well.
If
my diabetic patient doesn’t follow my advice, I must not have tried
hard enough, the logic goes, so I should be penalized with a smaller
paycheck.
The
dark side of such a system is that doctors might cull such patients
from their practices in self defense and not accept new ones...
Vik Khanna responds.
___
More to come...
