Monday, May 18, 2009

Role of the EMR in Managing Community Health

Is a community wide EMR essential to actually help optimize population health?

Our conversations continue with several community groups who are interested in organizing themselves to compete in the Healthcare X PRIZE. This has certainly led to some promising developments in our prize development process. One of the interesting items of internal debate has been the value of electronic health records, whether or not they should be required as part of the rule set for teams.

It’s still an open item, although we are leaning towards being less prescriptive as opposed to more. However, many of the ways we anticipate teams will interact with participants requires some of the data and functional capabilities of an EMR. Researching how others have addressed this issue led me back to the New Ulm Project, where the community wide implementation of an EMR was a primary reason for New Ulm being selected as the test site.

Comments from their report - "The Heart of New Ulm: A Vision for the Future":
Centralized Healthcare including an Automated Medical Record

Prior community CAD interventions have not had the luxury of centralized healthcare that includes automated medical records. Within the city of New Ulm, care is provided by a single health system, and currently, 16,470 (96% of the population) patients have patient records in the automated medical record. An integrated care delivery system has the capacity to systematically identify individuals at risk for CAD and those with active disease, create targeted interventions (e.g., clinic-, phone-, web-, or mail-based), and tailor treatments to the individual. It also serves as a communication vehicle between all members of the care team, which is vital for coordinated care. The automated medical record provides the needed information linkages and is designed as a closedloop system that allows for both input and feedback. Based on medical record data, interventions can be designed to keep healthy people healthy (e.g., health promotion programs), offer risk reduction health behavior change programs to individuals at moderate risk (e.g., weight management or stress management programs), create algorithms to identify individuals at high risk who may benefit from more intensive interventions (e.g., calcium scoring), and more effectively manage individuals with active disease who are not achieving optimal care goals (e.g., clinical interventions and disease management programs).

Value of Automated Medical Record in Community Health Initiative

While use of health promotion, primary prevention, and secondary prevention strategies in community-wide interventions is not new, what is new is the use of centralized care—especially the automated medical record—to target and tailor interventions to achieve optimal outcomes. The automated medical record provides unique opportunities to help individuals achieve optimal health and care through individual and system support, for example, at the:

Individual level — Individuals can receive feedback reports based on data entered into the medical record to learn about their risks for having a myocardial infarction, how well they are doing at managing their risks (e.g., blood pressure is normal or high), and what programs are available to them to help them improve their risk profile and stay healthy.

Provider level — Providers can receive feedback reports based on data entered into the medical record on the number of patients achieving optimal care targets (e.g., LDL-C and blood pressure in recommended ranges based on risk profile), patients’ refill patterns for prescribed medications (i.e., medication compliance), and health behaviors (e.g., tobacco use). All of this information can be utilized to provide quality care to patients and provide advice and appropriate referrals to patients during encounters that offer the “teachable moment.”

Clinic and care system level — At the systems level, reports can be generated to assess achievement of primary and secondary prevention goals, implement systems-level interventions (e.g., disease management or medication-compliance programs), and even generate employer-specific aggregate reports that could be used to offer and implement worksite-based health promotion, disease prevention, and disease self-management programs.
Seems like a compelling endorsement of a system wide EMR as a foundation for transformation. Other large systemic systems have all implemented EMR’s as part of their transformational strategy (Kaiser, VA, Intermountain, etc). Despite this evidence, we still have abysmal adoption rates and systems that are missing core functionality and feature sets that would allow greater proliferation. While we may not make this an explicit requirement, it seems like most teams will need many of the capabilities found in current EMR’s but may need to develop enhanced population management tools.

We look forward to getting additional input on this particular design element.
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