Over an ordinary bowl of morning cornflakes, patient Jill swipes open her phone to catch up on news.
But it’s not political commentary or social network updates, it’s news about her: a review of how she performed on her movement goal yesterday; how her resting heart rate this month, on average, compared to last month’s; how her sleep habits may be contributing to productivity challenges; and the latest research about her chronic disease. A digital coach even sends encouragement, highlighting key metrics for optimal disease management and health. All before she’s left for work, this patient has a clear picture of what she needs to do to improve or maintain wellness for the day.
Jill’s physician also has access to the patient-generated health data (PGHD), in addition to typical clinical metrics from diagnostic exams and labs. Alongside meaningful data from other patients, the physician can identify patterns and trends to provide more comprehensive clinical care that focuses on outcomes. He can even send electronic reminders and support about health goals along the journey.
The technology to enable such proactive engagement regarding health decisions is already available, but we need the right kind of regulatory support to see these capabilities play out to their full capabilities.
Opportunities to improve
Making use of high-volume and disparate clinical data and PGHD within today’s practice’s workflow is no simple task. The EHR must be able to process this data into actionable insights, enabling a medical records system that feels both patient-centric and physician-centric.
As if this challenge wasn’t daunting enough, some regulatory demands constrain the ability to navigate the data with ease. Broad industry requirements demand fulfillment of certain standards that may not be relevant to particular specialties or patients. A physician may need an EHR to capture specifically actionable data such as vital signs, lab values, medications, diagnosis or procedure codes and others. Many of the EHR systems today are either pre-canned to only look for certain data elements or only meet the basic regulatory requirements.
Some regulations fail to function as intended when they require health technology vendors to meet a certain standard but the provider or recipient of that interoperable inbound or outbound data is not required to meet said standard because it is not directly accountable to CMS or the ONC for its business. A good example is a lab test attestation requirement; EHR vendors are required to adhere to the LOINC engineering code when receiving lab results to enable the practice to report metrics for regulatory compliance. However, laboratories are not mandated to use LOINC codes. As a result, should the lab use a different code, the physician either loses performance credit or has to manually report it. The industry certainly has opportunities to regulate collection of meaningful data through the EHR to provide clinical value to providers and patients.
In the still prevalent fee-for-service healthcare system, payers drive the intense demand for physicians to collect and document specific data. The objective does not help physicians provide better clinical care. It falls on physicians and their technology providers to account for the disparities between what the regulations demand and the type of data physicians choose to collect based on patient need. The primary way of bridging the gap is to design a flexible and customizable practice workflow, highly tailored to specialty and patient need. Most EHRs are built to support multiple medical specialties and general workflows within the practice; however, with proper customization capabilities, physicians can configure the EHR to suit their workflows. This involves taking time to evaluate who is doing what activities, what most time-consuming tasks are, and how to streamline them within the EHR.
The challenge is the workflow patterns are different for different patients and are dependent on their disease conditions. For example, patients whose insurance plans require authorizations and referrals will need a workflow accommodating communications with other physicians’ offices. Some of the organizations may not have proper systems in place—the industry’s perennial interoperability challenge—and require manual interventions. As part of the upcoming information blocking regulations, the ONC is requiring that clinical data on patient encounter be sent in an interoperable fashion as part of the clinical document architecture (CDA). However, the specifications must be less ambiguous regarding “reasonable” data the regulators are looking to collect. If you ask 50 physicians what their progress notes do or should contain, you’ll get 50 different answers. The result, from a regulatory perspective, is to require the collection of significantly more data than is needed for any given point of the patient experience.
Consequently, the provider is forced to think more about collecting the EHR data for regulatory and reimbursement purposes than for the immediate patient need. That’s where the technology must come in: it needs to enable providers to create notes with reportable data as regulatory changes occur, without concerns about compliance.
Thinking about the next steps
While regulatory requirements of the ONC and meaningful use must be met, it’s also important to think about what other forms of data within the EHR could be actionable for clinical care. For example, many practices now have challenges caring for patients with social complexities, which require streamlined screening and referrals to community organizations or other resources. Yet, there’s no solid program broadly adopted—even state by state—that shows a physician that his patient could benefit from, for instance, a different living environment, and outline a local resource and a protocol for connecting the patient with the resource. The absence of these types of standards are critical gaps.
Moreover, the industry would greatly benefit from access to population-based health reporting based on certain data elements agreed to by all stakeholders. This would give the providers lists of patients that meet a specific criterion; for example, diabetes patients living in low fresh food access areas, and then the action plan to assign for tracking. From that, the physician could see within the EHR the patients who are on a care plan, who are on a plan but not following it, and who should be on the plan but aren’t. This list would be managed directly by provider staff and customizable based on the patient population and relevance of social determinants.
Keeping up with patients
In addition to non-clinical data such as social determinants, patients increasingly generate data through wearables. While PGHD data is absolutely relevant in the future of healthcare, there’s currently broad skepticism in the medical community about data quality and how it impacts the legitimacy of the patient chart. From the hardware of wearables to the software to the output format, providers are hesitant to drive EHR integration because they are accountable for what’s in the patient chart as part of the clinical treatment picture. There’s a need to standardize how specifically that data can be part of the chart because it has real value: sleep quality, heart rate, footsteps in a day. The physician mustn’t be held liable for the data’s integrity but empowered to use it to help patients.
Patients are already using social media and other online personalized health networks to piece together health data elements and get their own answers. The industry likewise should use data already available at the point of care to help surface better treatment plans and outcomes. Furthermore, healthcare must keep pace with the retail-like experiences of other industries to engage patients digitally.
Personalized insights, when integrated into the EHR through standardization and with regulatory oversight, have the potential to transform medicine. Let’s not miss out on the opportunities integrated data affords us. If we wait for the financial incentive to do so, it might be too late for many patients.
Stephen Dart is vice president of engineering at AdvancedMD.