Using HIT to Drive Clinical Integration, Patient and Physician Engagement and Population Health Management

Since passage of the HITECH Act, which was part of the American Recovery and Reinvestment Act of 2009, healthcare providers have been gearing up their healthcare information technology implementation plans to meet meaningful use requirements and gain financial incentives. In addition to providing a "carrot" to providers, the HITECH Act, also included a "stick" — providers who do not achieve stage 1 meaningful use by 2015 will have their Medicare payments reduced — propelling many health systems to kick their HIT efforts into high gear.

Towards meaningful use

Mercy began its journey toward electronic health record implementation and computerized physician order entry 10 years ago. Beginning in 2004, we rolled out CPOE across our four hospitals. At that time, there were no government mandates for adopting HIT or meaningful use criteria; however, our health system was committed to implementing these technologies because we recognized it was where healthcare was heading, and it was the right thing to do for our patients. While there were challenges surrounding implementation and being a CPOE pioneer, the use of our EHR for CPOE is now well engrained into our culture. All four of our metro-Toledo area hospitals have attested for both Medicare and Medicaid stage 1 meaningful use, and that's something we're very proud of.

The goal behind these efforts has always been to improve access to up-to-date clinical data to guide clinician and patient decision making, thereby improving quality, safety and efficiency of care. We're achieving that. For example, our tertiary care hospital reduced medication errors by 67 percent in the first year after we switched to CPOE and bar coding medication administration. We hope to continue to expand access to data as we further integrate our records with affiliated physician offices and eventually other systems. At Mercy, we plan to not only use our HIT systems as tools to facilitate integration but also to drive patient engagement and population health management — all of which will be core competencies of health systems under healthcare reform.

A key reason for our success has been physician engagement in the process. Decisions around EHR policies, processes and order set development were physician driven. Health system leadership invested in physician involvement by entering into contracts with physicians who participated in the various committees around our HIT efforts. We created a "Physician EHR Design Committee" to guide CPOE implementation and an “EHR Oversight Committee” to oversee clinical policies connected to our HIT initiatives. The contracts compensated the physicians for their time and effort but also served as formal mechanism for accountability. These committees required time, effort and "homework" beyond that expected in typical medical staff committees.

Our initial focus was the acute care environment. However, in Oct. 2011 as part of Catholic Health Partners, Mercy implemented CarePATH (Epic EHR) in all Mercy-owned physician offices and clinics. We strategically decided to launch the ambulatory EHR across all outpatient sites on the same day. The rational was  we wanted to have all sites on the same EHR platform rapidly because patients are often served by multiple sites concurrently. The "big bang" implementation of 233 attending physicians and 186 residents in 72 practices/clinics brought us to a "one patient, one chart" environment in record time. Now that each outpatient site is live, we'll work throughout 2012 to optimize CarePATH at each location and to reach meaningful use attestation under the Medicare or Medicaid option. Unlike hospitals, which can attest for both Medicare and Medicaid, physicians must choose between the two. Medicaid payments for meaningful use are higher, so our system will work to determine which physicians are eligible for the Medicaid program and enroll them there.  

Integration
In 2012, we will begin the implementation process to replace our current inpatient EHR with CarePATH. Doing this will provide us true integration across inpatient and outpatient environments, thus moving us closer toward our ultimate goal of providing current clinical data when and where it's needed — a goal that should guide every health system's HIT decisions.  

Additionally, we plan to make the ambulatory CarePATH EHR available to Mercy's affiliated physicians using a subsidized model. Allowing our independent physicians access to this system is important because it improves our ability to share information and to coordinate patient care. However, we recognize that not all physicians, and certainly not all hospitals, use or will use Epic EHR. Accordingly, Mercy is working closely with Ohio's statewide health information exchange to test ways providers across the state can best share medical record data. As we move toward a payment system that rewards value-based, coordinated care across the care continuum, our ability to share and receive information from outside providers will become critical to our success.

Engagement
We also hope to use HIT to increase patient engagement. We currently offer an online patient portal called MyChart which allows patients to access their medical records and lab results, request refills, send messages to nurses and physicians and make appointments. Patients can access the portal from any computer as well as most tablets and many smart phones. Some within the industry have voiced concern over allowing patients to see this type of information, but at the end of the day, the information belongs to the patients. Our goal has always been to improve access to clinical information, and the patient portal does just that. We have safeguards. For example, certain positive test results are not released to MyChart until the physician chooses to release the information (presumably after appropriate discussion with the patient).

Consider this scenario: How engaged would you be with an airline that could only be reached from 9 a.m.-5 p.m., is closed during lunch and doesn't have a website? Chances are you'd never consider buying a ticket from them. But this describes a great deal of medical practices today. The patient portal makes it easier for patients to interact with us and offers them the access they need to be engaged in their care. In a future that rewards physicians and health systems for keeping patients healthy, we must do everything possible to engage patients in their health.

Population health
CMS and the Institute for Healthcare Improvement share a vision of improving healthcare and improving the health of populations while decreasing the cost of healthcare (or at least bending the cost curve). To start, we hope an integrated outpatient and inpatient EHR combined with an health information exchange strategy will improve care coordination, enhance patient service, aid our affiliated and employed physicians while reducing duplicate testing and overall health care costs. Well-built order sets that incorporate evidence-based clinical practices and take into account cost issues (for example, generic drugs are the default option) also improve our position under value-based reimbursement by making the most appropriate clinical decision the path of least resistance for clinicians. We hope to be able to analyze data pulled from our EHRs to adjust clinical pathways and order sets as appropriate. Finally, for Mercy, and other health systems, the CMS and IHI vision challenges us to focus on population and community health. Not only do we plan to use the data gleaned from our medical record systems to help us make better clinical decisions, but we also plan to monitor the health status of the populations and communities we serve.

Looking ahead
Mercy is committed to implementing an HIT system that will help us integrate with other providers, engage patients and improve the overall health of the populations we care for. While it will take us time to get there, we feel we're progressing well. For other health systems interested in what we've learned thus far, I'd say nothing is more important than physician engagement and physician leadership and continuous communication about how HIT will allow physicians and other clinicians to perform the functions that will be required of them in the future. HIT implementation needs to be a clinical project.

Of course, HIT alone isn't going to get us to where we need to be, but it is a major component of the capabilities required to reach the larger goals of reform. The question should never be, "Which HIT product  should we implement next?" Instead, the question must be "How can these tools be used to reach clinical integration, support payment reform, engage patients and manage populations?"

Kenneth Bertka, MD, is a family physician and vice president of physician clinical integration at Mercy, a seven hospital and physician group system based in Toledo, Ohio.  Mercy is a member of Catholic Health Partners, the largest healthcare system in Ohio.

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