Improving IT's ability to get the right care to the right patients

CHICAGO—For a successful future, patient-centered medical homes will rely on several aspects of health IT, said David Bates, MD, MSc, speaking at the Healthcare Leadership Forum on Sept. 30. Bates is chief quality officer, senior vice president and chief of the Division of General Internal Medicine at Brigham and Women's Hospital in Boston as well as medical director of Clinical and Quality Analysis for Partners HealthCare.

Medical homes are different from traditional healthcare in that care is distributed among care team members, there is a big focus on access for patients, there is an emphasis on managing chronic conditions and transparency regarding performance.

Bates co-authored a paper on the future of medical homes which argued for the need for seven major areas of health IT to advance the care model.

“One key foundational thing is having the right problem list in the patient record,” he said. Partners built a tool that goes through records to find clues indicating that a patient might have a problem not on the problem list. The tool has been “enormously popular,” and has resulted in a 48 percent increase in items added to problem lists, he said.

In the future, Bates said he expects much more complex rules for decision support than are in use today. “We will start to be taking into account an array of factors--not just one or two things.” He also said he predicts that through leveraging analytics, systems will be much more directive in certain situations and “give providers a strong push about things that need to be done.” Eventually, he said decision support tools will sit in a repository and users will pull rules in when appropriate.

Population management tools need a variety of functions, he said, and should offer different front-end views for different providers. They also need the ability to generate lists. “So far, highly functional multi-disease tools are not widely available. We need these badly.” Bates also wants the ability to abstract data from existing records and staff trained to interact with registries. “In my clinic, we’re doing a pretty good job with diabetes but we’re hopelessly inadequate with everything else.”

Bates cited the use of whole panel views at Kaiser where users can look rapidly to see how they’re doing. “That’s the kind of thing we have not had that would be really great. Team care is going to be absolutely critical for getting to the next level. It involves getting to relationship-centered care.” Most EHRs don’t support this very well, he said.

Bates said he thinks personal health records (PHRs) “are key going forward. They will level the playing field.” They also have the potential to increase patient engagement but face hurdles such as uncertainty as to the best architecture, a lack of patient uptake and provider hesitancy.

Bates cited another paper he co-authored that was published over the summer which covered six use cases around improving organizational efficiency. One use case is high-cost patients—that 5 percent that account for half of healthcare spending. The first step in managing those patients, he said, is identifying that group by increasing data about mental health, socioeconomic status, marital and living status and more such information. “That’s likely to help us figure out what to do. One of the most important things is to identify specific actionable needs and gaps to help keep that person from being so expensive.”

Hospital readmissions is another use case covered in the paper. Now that the federal government has strongly incentivized providers to avoid 30-day readmissions, “you should be using algorithms to predict frequency,” Bates told his audience. Something can probably be done for about 30 to 25 percent of these readmissions by tailoring interventions and then ensuring the patient gets the intervention. “Actually doing something is really hard,” he acknowledged.

Decompensation is another use case and monitoring patients is important, especially outside of ICUs. This will improve, Bates said, with the use of wearables to track many variables. He cited a device that measured pulse, respiratory rate and movement which reduced the number of subsequent ICU days by 47 percent.

Because chronic diseases are extremely costly, predicting a trajectory “could enable caregivers to target complex and extensive therapies to patients who would benefit the most.”

With the shift from fee-for-service to fee-for-value, the risk payers used to assume “is coming to us,” said Bates. “If we don’t manage it well, we’ll suffer the consequences.”

Prospective payment approaches are going to become the norm, he said. “Medical homes as a structure is a transformational idea.” The form may evolve beyond ACOs, he said. “We have to start using analytics. Every other industry already uses it a great deal. It’s low-hanging fruit for us.”