Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large,
Urologists who own advanced imaging centers will be directly at risk.
Today, almost 10 years after the HITECH Act catalyzed the modern era of electronic health records with $35 billion of incentives to hospitals and providers, many are disappointed with the current state of affairs. As reported in a recent study, some feel the EHR is the most significant contributor to physician dissatisfaction and burnout (Mayo Clin Proc 2016; 91:836-48). Policy makers wonder whether the incentives have generated a return on that investment beyond laying a foundation of disparate, disconnected local systems.
The Office of the National Coordinator for Health IT combined two meta-analyses in 2013 and concluded that the impact of meaningful use (MU) functionality on quality, safety, and efficiency (cost) was 60% positive, 8% negative, and 32% mixed or neutral (bit.ly/MUimpact). I’m not sure many urologists would agree with that conclusion today. As we enter the post-MU world, I offer my own observations and predictions: where we are today and what I think the near future holds for health information technology.
Regulations still govern health IT vendors and their customers. Despite the widely celebrated end of the MU and Physician Quality Reporting System programs, the basic requirements for physicians remain the same under the Merit-based Incentive Payments System (MIPS), which most urologists will be participating in for the foreseeable future.
To give credit where it is due, many of the MIPS requirements have been relaxed and the timelines for other requirements-such as the transition to the latest certification requirements-have been extended. Vendors will still have to make major investments to meet regulatory requirements, and those costs will likely be passed on to customers directly or indirectly (in the form of delaying bug fixes, feature requests, or even a forced migration to another EHR if their vendor doesn’t make it). A relaxed timeline for urologists impatient about improvements in their EHR may serve to delay their gratification. Also, for as long as the evaluation and management coding paradigm underlies physician reimbursement, EHRs will continue to fuel unwieldy notes, extra documentation that does not improve care, and user dissatisfaction.
Next:More regulations comingMore regulations coming
Regulations will keep coming. The 21st Century Cures Act (Title IV-Delivery) has yet to be implemented, but you can certainly expect regulations that define information blocking, address health information exchange, and further empower patients with improved access to their medical records. These same themes constitute the core initiatives of the Centers for Medicare & Medicaid Services (CMS) recently announced by its administrator (bit.ly/EHRinitiatives). Urologists will soon feel new regulations that incentivize (or penalize) physicians in the areas of direct messaging, patient portal enrollment, and electronic access to medical records.
But perhaps the most significant looming regulatory change that will impact urologists is the Appropriate Use Criteria Program (AUC) (bit.ly/AUCprogram), which derives from the Protecting Access to Medicare Act of 2014. This program has already been implemented (and delayed) along a future timeline wherein physicians who order advanced imaging tests will be compelled to consult certified “clinical decision support mechanisms” to ensure they are following evidence-based ordering. The enforcement is implemented by requiring the radiology-rendering provider to append proof of this consultation in the form of an authorization status (and presumably identifier) in order to be paid.
Urologists who own their own advanced imaging centers will be directly at risk and incentivized to manage the ordering very carefully. This author believes that the AUC Program, when fully implemented as currently envisioned-will create an expectation that EHRs automate AUC consultation and perpetuate the cycle of investment to meet regulatory requirements that so frustrate physicians today.
On the other hand, I think meaningful and user-friendly Clinical Decision Support (CDS) holds the highest potential for improving care, improving health, and reducing the cost of delivery-the famous “triple aim” of health care reform. You know CDS today for its intrusion-alerts for allergies, drug interactions, and failure to check a box for MU-that are ineffective or irrelevant and usually ignored. The CDS of tomorrow will interpret individual patient and encounter conditions and streamline the ordering of diagnostic tests or treatment of common problems in a way that saves the physician time and effectively improves care according to evidence. AUC is a baby step in this direction, but I see a not-too-distant future where this is the most important part of the EHR.
Urologists are making small strides in “value-based” models that will soon place new demands on the EHR and HIT. We need look no further than large primary care practices that have pioneered population health management to see the future of medicine. Simply stated, today’s urology practice is almost completely characterized by an office visit transaction (that may lead to a procedure). Just as we have seen in primary care, tomorrow’s practice will involve disease management of groups of patients, and much of it will occur outside of a traditional office visit. Some urology practices are dabbling in disease management-advanced prostate clinics, overactive bladder pathways, and chronic care management-with various degrees of success. The most common model I have seen employs “nurse navigators” to drive these programs with a heavy reliance on some sort of “data” and analytics.
Current obstacles to success of these programs are numerous: Most of the EHRs that urologists use have no population health functionality; extracting, refreshing, and using the clinical data from the EHR requires an investment and often a third party; clinical data is inherently incomplete because of variable adoption among users; many practices do not have anyone trained or skilled in basic analytics, including but not limited to navigators; and most of the programs implemented to date may-whether by design or coincidence-result in increased health expenditures, not savings. Practices pioneering these efforts are often finding that today’s tools are used for screening candidates, not population management.
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The urology practice of the future will require improvements in HIT to conduct effective disease management that does not require an advanced degree-candidate identification, automatic data population, intuitive dashboards, actionable information, and measurable outcomes.
Next:Look for deployment model to changeLook for deployment model to change
Most EHRs in urology practices are deployed “on premises” on physical servers owned and maintained by the practice. The practice incurs cost to maintain and upgrade that hardware, often with little return on that investment. The EHRs of tomorrow will, I believe, be mostly deployed in a hosted or cloud model. While each has its advantages and disadvantages, the hosted model is usually less expensive, easier to maintain and upgrade, and more secure (for the practice). Today, it is more challenging to extract data from a cloud environment than from a local server; I look for consumer demand and implementation of the Cures Act to change that reality.
Finally, what of natural language processing (NLP) and artificial intelligence (AI)? NLP is real, and has found early application in speech-to-text software that can convert unstructured data to structured elements. The accuracy of these tools has been studied in the peer-review literature and has its widest use in pathology and radiology reports, specialties that are disciplined and structured in their documentation. It has not been widely implemented in the conversion of free-form progress notes, and I do not look for EHR vendors to take the lead in this regard anytime soon.
AI is an exciting frontier with promise in clinical decision support and disease management-especially in medical oncology. As noted, I think EHR vendors and their users have more immediate challenges to overcome in their adoption of CDS and population health, and I look for AI to have a role in the intermediate time frame.
Bottom line: Today’s EHR is typically viewed as a necessary evil whose primary purpose is to create a progress note that supports getting paid for an office visit. Tomorrow’s user of health IT will expect-and actually use-technology to support making faster and more accurate decisions, review data quickly, communicate seamlessly with other providers and facilities, and drive the efficient management of populations of patients according to best practices. Perhaps the progress note will someday be a minor and optional feature of the EHR rather than the primary focus.
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