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Spurred on by Meaningful Use, there has been an explosion in the implementation of EHRs over the last several years. This tidal wave has been sweeping through the healthcare community, sucking up much of the available bandwidth that organizations have to deal with change of this magnitude. The effect is really no different than what other industries have been through over the last couple of decades beginning with the emergence of ERP systems in the late ’80s, early ‘90s. The organizations setting up EHRs have the opportunity to look back at the experiences those industries and to glean lessons learned. One of the biggest is that there will be a second wave, which we are already starting to see. This second wave is driven by the desire for information and knowledge. Folks realize that the instillation of technology to support operating standards, policies and business procedures via EHRs provides for a great source of transactional data. Data that is just waiting to be warehoused, given meaning, aggregated, sliced, diced and analyzed. The challenge here, and a trap that many fall into, is that the data can seem so close at hand, accessible and, on a small scale, manipulatable, that the cost and effort to deploy analytics solutions to get at the data aren’t that great. Invariably, after much investment and frustration at the inability to get all of the data, many realize that what they initially focused on was just the tip of the iceberg and that the effort of managing and distributing a large amount of information and knowledge across a large organization requires a great deal planning, time, people and investment. While not quite as invasive as the rollout of the EHR, the investment in analytics is substantial, must be planned and executed over a period of time.
Avoid the Trap
There are a couple of tell-tale signs that you’ve fallen into the trap. The first is the 80/20 rule, where you end up spending 80% of your time collecting, cleaning, organizing and making data available, leaving only a small amount of time to analyze and act upon it. The second sign is the executive dashboard, the situation where a large number of people spend a great deal of time every month, sourcing from the new EHR and other transactional platforms, aggregating, calculating and making available, with very little automation, to a select few (ie., the senior management team). A dashboard that others in the organization don’t have access to, nor, due to its highly aggregated level, is it of much value to, although I’m sure it’s been a source of many “fire-drills.” The “fire-drill” being painful in that the lengthy and manual manner, in which the particular dashboard measure is deduced, must be dissected in order to determine was there really an issue or is it related to the calculation and aggregation process. Then, if there is an issue, where? Typically, you’re already 45-90 days out from the occurrence of the negative event.
It’s Not Just About the Transactional System
What can health organizations do about this? First, they must realize that the implementation of the EHR creates both a great source of data and a need within the organization to aggregate that data, combining with other information from across the organization and from third parties. With this awareness, the EHR effort should be shadowed by one focused on developing a strategy, objectives and plans supported by milestones to deploy analytics in a controlled and deliberate manner. To successfully do so, it will be quickly realized that there are dependencies that must be addressed. Such as the need for data governance, inclusion of any master data management activities already underway and the need for an infrastructure that enables the transactional, analytical and other systems and devices to access and exchange data, whether an HL7 transaction, X12 out-going batch file, an EHR feeding the analytics store or a patient portal via SOA. Third are awareness, education and training. Analytics unleashed upon the employee population all at once can be analogous to drinking from the fire-hose. The effective use of analytics is driven by the ability of the organization, department, teams and individuals to clearly articulate a specific need for information, putting into the context of the particular business process(es), activity(ies) and task(s). Ideally, analytics are doing two things for us; 1) reinforcing that we’re meeting or exceeding the desired performance level, as we all need that periodic feedback that everything is ok and 2) an exception is occurring, which is where we’ve defined what it is to be operating normally and an event or occurrence has arisen that is outside the box, so the appropriate people must be alerted and have the ability to drill down into abnormal event to immediately begin identification and resolution of the issue.
What Does It Mean to Me?
How does all of this relate to Utilization and Population Health? Over the last few months, there has been a noticeable increase in activity amongst health systems around the desire to understand more about the dynamics of the marketplace they do business in and the population they serve. They are more aggressively pursuing sources of information outside the organization that can be combined with internal information to begin to paint a picture of not only the morbidity of the local population they serve, but the usage patterns the population is following in seeking out care. Seeking care isn’t as consumer-friendly as many would hope and most health coverage leaves the choice of access to the consumer. Health systems can begin to identify and track those patterns of utilization, situations of network leakage, repeat visits, begin to stratify the local population for risk, predict demand on facilities and impact to case-mix. To the extent the health system is pursuing community outreach and educational programs; this information can be input into designing these programs as well as way to measure their impact. The outreach and education can occur in conjunction with the PCPs and, potentially, the health insurance companies servicing that same membership. The unspoken objective of all is to better understand and improve on the outcome of care.
This is not only a time of great change, but I believe we are on the cusp of an evolutionary move forward. The collective stakeholders will need to work together, contrary to stereotypes, to provide an environment in that will support, encourage and foster movement down this path of improvement. Clearly, ICD-10 won’t be easy and it impacts each major stakeholder in different ways based upon where they are in the healthcare supply chain. My greatest area of concern and nexus of ICD-10 is with the quality and quantity of clinical documentation. Clinical documentation is the primary source for the generation of a bill or claim, amongst other things. I’m aware of isolated testing efforts to create or “code” bills using the ICD-10 code set. The results show that more than 40% of the bills cannot be created due to insufficient clinical documentation. To be fair, the particular efforts referred to were in facility settings and involved both diagnosis and procedure codes. I don’t know about you, but that’s disconcerting. Not just about the potential lack of information to code claims, but what does this mean about the usability of the information that is recorded? Does this mean that documentation standards are really driven by doing no more than is required to file a claim for payment? Even then, to accomplish that requires a capable and experienced coder who’s familiar with the nuances of the caregivers in their organization. With respect to usability, how can we meaningfully exchange information across the care delivery system and establish a robust patient record that’s a reference for future care? While ICD-10 may put a spotlight on this issue, the two issues aren’t tied at the hop. There’s no reason that improvements in the creation of clinical documentation cannot begin now. If you look at the root of the generalities being made about ICD-10, it’s really about having to spend more time on creating good clinical documentation.
Establish a Baseline
In Healthcare, we talk about how important security is, all the while secretly hoping and assuming that, as an organization, we’re in compliance and have all the appropriate safeguards in place. When discussing compliance, at the very least this refers to the baseline set by the HIPAA Security Rule and the many contractual obligations we have, including Business Associate Agreements (BAA), being a Covered Entity and confidentiality clauses.