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It's about much more than record-keeping.
By A. James Bender and Robert S. Mecklenburg
October 10, 2017
Americans are both undertreated and overtreated in a health care system that wastes up to $1 trillion a year and delivers profoundly uneven quality: Current estimates indicate that preventable medical errors are the third leading cause of death in the United States. Fifty-eight percent of patients referred to Virginia Mason, our medical center in Seattle, for back surgery would be more appropriately treated without an operation. Tens of millions of Americans, most with health care insurance, have never had appropriate screening for colon cancer. Electronic medical records can help correct these systemic defects.
Every day, online retailers use computer-based transactions to guide us through stepwise sequences to buy a pair of jeans, apply for a credit card, or book a flight. As we follow these electronic pathways, we can’t really go wrong: If we omit critical inputs or make an inappropriate choice, the program does not allow us to proceed until we get it just right. In the language of systems engineering, the transaction is “mistake-proofed.” And in the rare circumstance of a unique or very complex transaction, we can pick up the phone to work through the issue with a content expert. This same mistake-proofing process and technology embedded in the electronic medical record (EMR) can move us a great distance toward safer, higher quality, and more affordable health care.
Information technology has come late to health care delivery. But in 2009, federal regulations applied financial incentives and penalties to drive broad implementation of EMRs. While introducing this technology has been costly and disruptive to traditional medical practice, there is no question that patients and purchasers can receive benefits in terms of improving safety, ensuring necessary care, and avoiding unnecessary care.
EMRs improve patient safety by requiring computer-based physician orders that eliminate illegible handwriting and misinterpreted verbal orders. Checkbox options that offer providers only correct doses of medication prevent overdoses. When Virginia Mason Medical Center implemented computerized “order entry,” confusing or incorrect physician orders fell from 50% to near zero overnight. And at the bedside, nurses now compare a bar code on the patient’s wristband with the label affixed to medication to ensure the right patient receives the right medication. These safety features, delivered through the EMR, are now in common practice.
But just as the cell phone, originally designed as a mobile communication device, has been adapted to an unimagined array of additional functions, the EMR is serving as a platform for innovation and creativity. Progressive and tech-savvy provider groups are advancing the frontier of ensuring medical quality and collaborating with commercial EMR vendors. Long before innovations become commercially available, they are tested and refined as small-scale improvements programmed into an individual medical center’s EMR. Some of these innovations include 1) detailed prompts and reminders to avoid omissions in care, 2) transparency to engage patients and families in spotting lapses in care, and 3) adding medical intelligence to computer programs.
Detailed prompts can standardize and improve care. Evidence-based, best-practice guidelines are publicized for many common conditions but are often deeply buried in medical journals. The EMR can bring these guidelines to the point of care, directing practitioners in completing all necessary treatments. Intermountain Healthcare, a system that serves patients in Utah and Idaho, has developed many such guides and is working to embed them into EMR workflows.
Transparency on delivering recommended care, enabled by the EMR, cuts across the grain of traditional hospital culture. In the intensive care unit at Virginia Mason, electronic scoreboards in public areas display with red or green highlights the current treatment status of every patient receiving therapy to prevent the formation of dangerous blood clots in the legs. These highly visible screens enable patients and family members to join doctors, nurses and support staff in rapid identification and correction of incomplete care. Virginia Mason now experiences 100% compliance with interventions to prevent blood clots for these patients. (Disclosure: Virginia Mason receives in-kind support for contributions by one of us — Jim Bender — to the Cerner Physician Alignment Organization.)
Further, the EMR can move beyond prompts and reminders to apply the functions of rudimentary intelligence. When blood thinners or insulin are ordered at Virginia Mason, an internally developed program automatically orders the essential lab tests necessary to safely adjust these medications. On a larger scale, the EMR can also tap into remote databases and registries to select key data for an individual patient and bring this valuable information to the provider and patient at the point of care. Each of these advances frees providers to focus on those especially complex patients with conditions that are beyond the limits of standardized care and where experience and judgment are necessary.
A uniquely disruptive application of the EMR is its use to block costly and unnecessary care. In 2004, large Seattle employers came to our medical center seeking more affordable health care. From their medical-claims data we identified their highest-cost conditions, including back pain, headache, and sinus conditions. We identified an abundance of inappropriate care as a prime contributor to the high cost of these conditions. We discovered that the cost driver for each was expensive MRI or CT studies, many of which were not appropriate.
Virginia Mason providers developed a checklist that corresponds to evidence-based rules for ordering these tests and installed these on a homegrown computer page. If the ordering provider could not specify an evidence-based rationale for the test, the computer blocked the order. The result: As we “mistake-proofed” provider orders, advanced imaging for these conditions dropped 25%. We have since applied evidence-based decision rules to block additional inappropriate or unsafe practices.
Innovators are pressing forward at this digital frontier, showing how the EMR can be applied to achieve safer, more effective, more affordable health care. What will it take for others to cross this threshold? Our experience suggests three key factors.
The first is establishing explicit, best-practice standards to reduce needless variation in the management of medical conditions. Such standards have been implemented by groups where there is institutional alignment on quality. They include Virginia Mason, Washington State’s Bree Collaborative, Intermountain, and Geisinger. Medical specialty societies also have a role. They lack authority to implement standards but can facilitate alignment on recommendations that can be broadly adopted across U.S. medical practices. The Choosing Wisely initiative, founded in 2012 by the American Board of Internal Medicine in partnership with Consumer Reports, has engaged 70 professional societies to produce hundreds of recommendations aimed at engaging providers and patients in discussions to avoid unnecessary care.
Second, medical centers and vendors should work together to embed more of these protocols into EMRs to help physicians make the best decisions. A priority should be the development of “hard stop” tools that can block unsafe or inappropriate care (e.g., the ordering of an unnecessary imaging test). These applications of the EMR are in early development. One obstacle to progress is the cost of allocating clinical and technical personnel to install and maintain these projects: With medical centers under increasing financial pressures, the cost is limiting the custom development of these tools.
In addition, requiring providers to align with standards for best practice may challenge their traditional authority and revenue streams. But it is our experience that providers become supporters when they have an active role in developing clinical decision rules, they can override rules in unusual situations with a second opinion, and their higher quality care attracts new customers. As both customers and consultants to EMR developers, providers benefit by bringing their practical perspective to bear as these tools are designed and embedded in software platforms.
Third, purchasers should require adherence to evidence-based standards in bundled-payment contracts (a single price for all the care needed to treat a condition) and other value-based contracts with providers. Adding predictable pricing, warranties against avoidable complications, and transparent reporting of market-relevant outcomes reinforces accountability for providers to improve quality and affordability. Direct contracting between purchasers and providers allows employers to apply purchasing standards to providers as they would to other suppliers of goods and services. The State of Washington and other large private sector purchasers have contracts with providers with such elements. Market-based performance standards that place providers at financial risk if they fail to meet standards for safe and effective care will encourage them to use the same efficient computer technologies deployed by internet retailers to compete and thrive in a market for quality.
Providers that embrace the full functionality of the EMR will have an advantage in gaining market share and in lowering their costs. Most important, the best doctors will use the EMR to add the deep knowledge and protection of digital mistake-proofing to the art of medicine that they bring to each of their patients.
A. James Bender, MD
A. James Bender, MD, is medical director for clinical informatics at Virginia Mason in Seattle. His responsibilities include the deployment and use of the medical center’s electronic-medical-records system with a focus on the integration of safety and appropriate standards into clinical care.
Robert S. Mecklenburg, MD
Robert S. Mecklenburg, MD, is the medical director of the Center for Health Care Solutions at Virginia Mason Medical Center.
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