HealthAffairs: EHRs must evolve to integrate into medical home
More research is needed but the EHR will likely be a foundational element of the medical home, according to an article in the April edition of HealthAffairs.
“Together, they will play a key role in reducing costs and improving the quality and safety of care,” wrote David W. Bates, MD, chief of the division of general internal medicine and Asaf Bitton, MD, fellow in general internal medicine at Brigham and Women’s Hospital in Boston.
The authors stated that to achieve these goals, the EHR will need to evolve substantially as commercial record systems are underdeveloped with respect to telehealth, measurement of quality and efficiency, care transitions, personal health records and most importantly, according to Bates and Bitton, registries, team care and clinical decision support for chronic diseases.
“A medical home that improves outcomes and lowers costs…will build upon EHR innovations in the context of payment reform and patient-centered care,” stated the authors.
According to Bates and Bitton, only four peer-reviewed published studies of medical home demonstrations have been published despite hype around the idea. Although preliminary, the authors stated that the studies show that implementation of a medical home is associated with reduced costs and both lower emergency department usage and fewer hospitalizations for patient with conditions, such as congestive heart failure, that can often be managed on an ambulatory basis.
Citing that the studies also found an association with improved intermediate quality outcomes for a number of chronic diseases, including the proportion of patients achieving target levels for blood pressure, low-density lipoprotein cholesterol or glycohemoglobin, the authors stated that the “published results of these early medical home experiments suggest that many of these improved outcomes are attributable in part to improved use of EHRs, although we acknowledge that changes outside the EHR may have played a role [as well].”
In their examination of EHRs, Bates and Bitton stressed needing further development in clinical decision support, registries and team care domains.
According to the authors, a systematic review of decision support by Amit Garg and colleagues found that decision support improved providers’ process performance in 64 percent of studies while only 13 percent reported improvements in at least one care outcome. “However, decision-support tools that automatically prompted users to take actions and those that were developed by Garg and colleagues themselves were significantly more likely to be successful than tools that did not prompt,” Bates and Bitton wrote.
“With respect to the medical home, it appears that decision-support capabilities will be beneficial, although the evidence varies greatly by domain. Most studies show improvement in intermediate process outcomes as opposed to disease outcomes,” the authors wrote.
Registry functions, or applications that define patients with specific conditions while specifying their disease status, of most commercially available EHRs are poorly developed, according to Bates and Bitton. “These functions need to be dramatically improved so that nonphysician team members can identify, communicate with and proactively track and manage patients with a large number of chronic conditions.”
The authors noted the Registry Population Manager in the article as an example of a new tool with medical home applications. The tool identifies cohorts of patients with specific criteria which Bates and Bitton report as being able to increase the number of patients whose information nurses could review from 10-30 per hours to 300 per hour.
“A core concept of the medical home is that care is delivered by teams of providers including nurses, nurse practitioners, pharmacists, medical assistants and care coordinators who help primary care physicians promote better care. For this model to be effective, it will be essential to develop communication tools that allow practices to record goals shared by providers and patients alike,” Bates and Bitton wrote.
This type of functionality is “largely absent” from today’s EHRs and is in need of development and testing, according to Bitton and Bates.
According to the authors, external payment reform will be the key from the broader policy perspective to enabling medical homes to take hold and become financially sustainable, including monetary rewards for providers who manage patients better with respect to quality, safety, efficiency and the patient experience.
“Substantial research would lead to new understanding of how EHRs can improve care in medical homes,” concluded the authors. Bates and Bitton suggest that funders such as the Agency for Healthcare Research and Quality should target several areas including the most important in their view: research into new ways to promote team care.
“Together, they will play a key role in reducing costs and improving the quality and safety of care,” wrote David W. Bates, MD, chief of the division of general internal medicine and Asaf Bitton, MD, fellow in general internal medicine at Brigham and Women’s Hospital in Boston.
The authors stated that to achieve these goals, the EHR will need to evolve substantially as commercial record systems are underdeveloped with respect to telehealth, measurement of quality and efficiency, care transitions, personal health records and most importantly, according to Bates and Bitton, registries, team care and clinical decision support for chronic diseases.
“A medical home that improves outcomes and lowers costs…will build upon EHR innovations in the context of payment reform and patient-centered care,” stated the authors.
According to Bates and Bitton, only four peer-reviewed published studies of medical home demonstrations have been published despite hype around the idea. Although preliminary, the authors stated that the studies show that implementation of a medical home is associated with reduced costs and both lower emergency department usage and fewer hospitalizations for patient with conditions, such as congestive heart failure, that can often be managed on an ambulatory basis.
Citing that the studies also found an association with improved intermediate quality outcomes for a number of chronic diseases, including the proportion of patients achieving target levels for blood pressure, low-density lipoprotein cholesterol or glycohemoglobin, the authors stated that the “published results of these early medical home experiments suggest that many of these improved outcomes are attributable in part to improved use of EHRs, although we acknowledge that changes outside the EHR may have played a role [as well].”
In their examination of EHRs, Bates and Bitton stressed needing further development in clinical decision support, registries and team care domains.
According to the authors, a systematic review of decision support by Amit Garg and colleagues found that decision support improved providers’ process performance in 64 percent of studies while only 13 percent reported improvements in at least one care outcome. “However, decision-support tools that automatically prompted users to take actions and those that were developed by Garg and colleagues themselves were significantly more likely to be successful than tools that did not prompt,” Bates and Bitton wrote.
“With respect to the medical home, it appears that decision-support capabilities will be beneficial, although the evidence varies greatly by domain. Most studies show improvement in intermediate process outcomes as opposed to disease outcomes,” the authors wrote.
Registry functions, or applications that define patients with specific conditions while specifying their disease status, of most commercially available EHRs are poorly developed, according to Bates and Bitton. “These functions need to be dramatically improved so that nonphysician team members can identify, communicate with and proactively track and manage patients with a large number of chronic conditions.”
The authors noted the Registry Population Manager in the article as an example of a new tool with medical home applications. The tool identifies cohorts of patients with specific criteria which Bates and Bitton report as being able to increase the number of patients whose information nurses could review from 10-30 per hours to 300 per hour.
“A core concept of the medical home is that care is delivered by teams of providers including nurses, nurse practitioners, pharmacists, medical assistants and care coordinators who help primary care physicians promote better care. For this model to be effective, it will be essential to develop communication tools that allow practices to record goals shared by providers and patients alike,” Bates and Bitton wrote.
This type of functionality is “largely absent” from today’s EHRs and is in need of development and testing, according to Bitton and Bates.
According to the authors, external payment reform will be the key from the broader policy perspective to enabling medical homes to take hold and become financially sustainable, including monetary rewards for providers who manage patients better with respect to quality, safety, efficiency and the patient experience.
“Substantial research would lead to new understanding of how EHRs can improve care in medical homes,” concluded the authors. Bates and Bitton suggest that funders such as the Agency for Healthcare Research and Quality should target several areas including the most important in their view: research into new ways to promote team care.