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Crossing the Chasm withInformation Technology:Bridging the Quality Gap in Health Care

Prepared for:CALIFORNIA HEALTHCARE FOUNDATION

Prepared by:

First Consulting Group

Author:

Peter Kilbridge, M.D.

July 2002

Acknowledgments

First Consulting Group is a leading provider of consulting, technology and outsourcing services for health care, pharma-ceutical, and other life sciences organizations in North Americaand Europe. More information about FCG is available atwww.fcg.com.

The author would like to thank Joanna Case, Erica Drazen, and Jane Metzger of First Consulting Group for their time andinput. In addition the following individuals contributed to case studies and interviews: John Bachman, M.D., Mayo Clinic; Tim Bailey, M.D., University of California, San Diego; James Barr, M.D., Central Jersey Physician Network; MikeHindmarsh, MacColl Institute, Group Health Cooperative ofPuget Sound; Lesli Kennedy, McLeod Regional Medical Center;Eric Liederman, M.D., University of California, Davis; Paul Tang, M.D., Palo Alto Medical Foundation.

The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improvingCalifornia’s health care delivery and financing systems. Formedin 1996, our goal is to ensure that all Californians have accessto affordable, quality health care. CHCF’s work focuses oninforming health policy decisions, advancing efficient businesspractices, improving the quality and efficiency of care delivery,and promoting informed health care and coverage decisions.CHCF commissions research and analysis, publishes and disseminates information, convenes stakeholders, and fundsdevelopment of programs and models aimed at improving thehealth care delivery and financing systems.

The iHealth Reports series focuses on emerging technologytrends and developments and related policy and regulatory issues.

Additional copies of this report and other publications can be obtained by calling the California HealthCare Foundation’s publications line at 1-888-430-CHCF (2423) or visiting usonline at www.chcf.org.

ISBN 1-932064-02-8Copyright © 2002 California HealthCare Foundation

Contents

5 I. Overview

7 II. The IOM’s Ten Rules

10 III. Four Principles for a New Vision

of High-quality Care

12 IV. Twelve IT Applications

Patient Empowerment

Making the Care System Reliable and Safe

Care Relationships Beyond the Encounter

Public Accountability for Quality

28 V. Organizational Challenges

31 VI. Conclusions

32 Endnotes

Crossing the Chasm with Information Technology: Bridging the Quality Gap in Health Care | 5

THE INSTITUTE OF MEDICINE’S SECOND REPORTin their three-part series on the quality of health care in America,Crossing the Quality Chasm (IOM II), describes fundamentalflaws in the current care system that interfere with the consis-tent delivery of quality care. Memorably, the IOM authorsconclude that between the quality of health care we currentlyhave and that which we could and should have “lies not just agap, but a chasm.”1 Deriving its conclusions from extensiveresearch and case studies, the IOM report cites specific forcesthat have combined to create the present predicament:

� Growing complexity of science and technology, withlengthy delays between innovation development andimplementation in clinical practice;

� Increase in chronic illness burden, with a health care system centered around acute care delivery;

� Inadequate use of information technology; and

� Payment schemes that produce conflicting incentives and do not encourage quality improvement.

The IOM authors acknowledge that information technology is one critical ingredient to any solution. While their reportprovides a convincing argument that the chassis is broken,it offers little practical information about how to go about therebuilding. Rather, it provides a set of ten rules or goals for the future that will promote the transformation of the systemand move American health care “across the quality chasm”:

1. Care based on continuous healing relationships.

2. Customization based on patient needs and values.

3. The patient as the source of control.

4. Shared knowledge and the free flow of information.

5. Evidence-based decision-making.

6. Safety as a system property.

7. The need for transparency.

8. Anticipation of needs.

9. Continuous decrease in waste.

10. Cooperation among clinicians.2

The objective of this report is to describe and, where useful, illustrate with case examples,how currently available tech-nology is being used by careproviders in ways that supportthe goals of IOM II.

I. Overview

The objective of this report is to describe and,where useful, illustrate with case examples, howcurrently available technology is being used bycare providers in ways that support the goals ofIOM II. Since technology cannot be implementedin isolation and process change is critical to qual-ity improvement, this report discusses some ofthe organizational challenges that must be dealtwith when implementing these technologies.

The principle emphasis of IOM II is on qualityof care, and this report focuses on applicationsthat specifically support clinical processes (as opposed to financial, administrative, etc.). In addition, the report emphasizes the outpatientsetting. There are several reasons for this: First,the IOM principles concentrate heavily on systemic, rather than setting-specific, challenges,and many of the greatest challenges exist outsideof the acute care facility. Second, there is muchless known and written about quality improve-ment initiatives in the outpatient setting. Third,while there remains much progress to be made,the use of clinical information systems is wellestablished in the inpatient setting, whereas adoption of technology affecting care quality inthe outpatient setting is still in its relative infancy.

This report is not an attempt to “cover the waterfront” of available technologies; there arecertainly other good examples beyond those considered here. Rather, this is a representativesampling of some important categories of tech-nology and their application to the objectives of the IOM II report.

6 | CALIFORNIA HEALTHCARE FOUNDATION


THE TEN RULES CREATED BY THE IOM IIcommittee state particular goals for improving the quality ofhealth care. This section defines these rules and considers howcurrent day processes work (or do not work) around each. Inmany cases, the rules serve to point up deficiencies that nowexist in health care.

Rule 1: Care Based on Continuous HealingRelationshipsThis rule refers specifically to patients’ access to care. Thehealth care system should be accessible to patients at all times,by multiple means (telephone, online, in person, or other).

In the typical practice setting, access to care and information isa nightmare from the patient’s perspective. A patient phoningto schedule an appointment typically faces an automatedanswering machine or service, and must navigate through aseries of choices to speak with a practice administrator, some-times spending significant periods of time on hold. Then,because a busy practice may be scheduled months in advance,the patient could have a significant waiting period before anappointment is available. Patients calling the practice withquestions, refill requests, or urgent medical problems frequentlyface long waits as well. The result is that many become dis-couraged and feel compelled to schedule an office visit to getthe attention they need, when often their needs could be metsimply by better communication.

Rule 2: Customization Based on Patient Needsand ValuesProvision of care should be able to accommodate patient-specific requirements and desires. Patients’ preferences—forexample, about alternate therapeutic avenues with differingside-effects and probabilities of co-morbidity—should beactively solicited and incorporated into clinical decision-mak-ing; and patients’ decisions should be respected by physicians.

Patients should have access to information about their care,and should have the power todetermine their degree of partic-ipation in decision-makingabout it.

II. The IOM’s Ten Rules

Rule 3: The Patient as the Source ofControlOverlaps with Rule 2; it states that patientsshould have access to information about theircare and should have the power to determinetheir degree of participation in decision-makingabout it. The emphasis here is on access to information and choice about level of involve-ment in decision-making.

Traditionally, the degree to which patients havebeen fully informed of the options available tothem and involved in decision-making has variedgreatly. Providing patients with better access toinformation about wellness and disease can bedone in many ways. Some information sourcesare available to patients independent of theirinteraction with their caregivers; others can beprovided by physician practices and used toenhance the quality of care as well as the patient’sexperience in the health care system.

Rule 4: Shared Knowledge and the Free Flow of InformationThis rule further emphasizes granting informa-tion access to patients, particularly access to theirown medical records. Patients should also havethe opportunity to correct—without deleting—provider-recorded information in their records,and be able to learn who has accessed theirrecords. Seemingly a simple proposition, in severalstates patients are in fact barred from gainingaccess to their medical records.3

Rule 5: Evidence-based Decision-making Medical decisions should be made not on thebasis of personal anecdotal experience, but basedon the best current evidence and understandingof the subject. Rule 5 addresses the need toreduce unnecessary variation in care.

An important component of promoting adherenceto evidence-based practice is making the best evidence on current standard of practice availableat the time and place where decisions are beingmade. This requires determining the best prac-tice, assembling the specific description of how to adhere to the practice, and presenting it in atimely fashion. Best practice for many commonconditions has been the subject of numerousstudies and consensus statements; clinical practiceguidelines exist for many conditions.

Rule 6: Safety as a System Property Current understanding of safety in complex systems holds that safety is not principally afunction of individual responsibility, but rather isdetermined by the system in which care providersand patients operate. Improving patient safetyinvolves fundamental changes in the culture ofthe average care delivery setting: emphasizing discovery and learning from errors, rather thanhiding them; encouraging error reporting, ratherthan assigning blame; and incorporating safetyplanning into all aspects of clinical operations.

Safety is a very broad topic. The most commonarea of attention for safety improvement has beenthe medication management process.4 In the outpatient setting, electronic prescribing has beenpromoted as a medication safety measure.5 A previously published research report discussed atlength the safety benefits of electronic prescribing.6


Rule 7: The Need for TransparencyTransparency here means public accountabilityfor quality. The care system’s performance metricsshould be available to patients to consider intheir decision-making, and errors or adverseevents should be communicated to patients.Some argue that medical errors (process errors)and/or adverse events (adverse outcomes) shouldbe reported to public databases.

The transparency rule raises challenging issues for today’s health care system. The principalobstacle to transparency in the area of error oradverse event reporting is fear of litigation.Indeed, some have argued that fundamentalimprovements in patient safety cannot occuruntil the American tort system undergoes signi-ficant reform.7 Nonetheless, several kinds of performance information are being made widelyavailable. These are discussed later in this report,along with the debate surrounding them.

Rule 8: Anticipation of NeedsPatient care should be proactively managed—anticipating the monitoring and therapeuticneeds of those with chronic illness, and reachingout to “non-participants” to draw them into thesystem for preventive care and screening.

The current health care system operates mostly inreactive mode, addressing illness when it presentsrather than focusing on prevention and proactivemanagement of chronic conditions. The latterhas received much attention in the last decade,largely in the form of disease management pro-grams sponsored by health plans, pharmaceuticalcompanies, or provider organizations. This report looks at approaches to assisting providersand patients in working together to manage illness, rather than on disease management com-panies’ efforts, which are numerous and exceedthe scope of this research.

Rule 9: Continuous Decrease in WasteThis rule refers primarily to today’s “penny wise,pound foolish” approach to medical care, whichthe IOM committee argues amounts to limitingaccess, reducing investment in resources, andconstructing other barriers to care in the name of cost reduction. Ultimately, the IOM report’sauthors believe, improving the quality of care will lead to greater efficiencies.

Rule 10: Cooperation among CliniciansAn emphasis on cooperation should replacetoday’s emphasis on clinician autonomy ifpatients are to receive the best possible care. The IOM authors believe too much attention isgiven to distinctions between professional rolesand their respective tasks, which inhibits a more practical, patient-focused approach to care.Cooperation requires not only new attitudes, but also new ways of working. Rule 10 promotesgreater used of team-based approaches to caredelivery, better standardization of procedureswhere practical, and more attention to meetingthe patient’s needs effectively. These aspects of care delivery are facilitated by information sharing among providers.



THIS REPORT ORGANIZES THE TEN RULES OFIOM II, which point to specific deficiencies in the current care system, into four general “principles of care” that describe the future ideal health care system.

1. Patient EmpowermentThe degree of empowerment, or involvement in decision-making around care, is each patient’s choice; but in the future,all patients are able to be active decision-makers and collabora-tors in their own care. They have a better understanding oftheir care, and can access a variety of tools to assist them inadministering self-care. Patients also contribute to improvingthe safety of their care, by being better informed and aware of the details of care.

Information management implications of patient empower-ment. Empowerment requires knowledge, and the means touse it. Specifically, patients should have ready access to healthcare information, including disease-specific information, pack-aged for non-clinician consumption. They should also haveaccess to their personal medical information and to decision-support tools for self-care.

2. Reliability and SafetyIn the future ideal health care environment, patients knowthey can rely on receiving top quality care. The health care system and its components perform reliably in all aspects ofcare delivery. Physicians consistently practice according to theprinciples of evidence-based medicine, and are able to do sobecause they have access to necessary knowledge at the criticalmoment. Different clinicians involved in the care of a patient,or population of patients, communicate and cooperate as amatter of routine. A reliable system is necessarily safe and efficient; errors of omission and commission are minimizeddue to appropriate decision support. Safety is considered the cornerstone of quality and is treated as an integral consid-eration in all aspects of care delivery.

III. Four Principles for a New Vision of High-quality Care

Information management implications of reliability and safety. Movement toward a highlyreliable care system requires:

� Providing clinicians with clinical decision support at the critical moment, including evidence-based knowledge in the context ofpatient-specific data. Examples include druginteraction alerts at the time of medicationprescribing (which improves safety), andreminders for specific guideline-based inter-ventions during the care of a patient withchronic disease. These kinds of decision support must be provided in a manner thatfacilitates—and does not complicate—theprocess of care delivery. Information should be presented in a patient-centric view for individual patient care, and also in a popula-tion or aggregate view, to support populationmanagement and quality improvement.

� Information sharing among clinicians andinformation access for clinicians. Cliniciansmust be able to share observations and data,and multiple clinicians must have access to a given patient’s data at their fingertips,regardless of their locations.

3. Care Relationships Beyond theEncounterRelationships are defined by collaboration be-tween patient and provider, not just face-to-faceinteraction. In the future health care system, thephysician-patient relationship has evolved beyondencounter-oriented care to a fuller, continuousand ongoing relationship. Physicians receivemore information about patients longitudinally,not just surrounding office visits. Care is deliv-ered proactively; patients are confident that theirchronic illnesses are monitored by caregivers

beyond the periodic office visit. They are able tocommunicate self-care data to providers, who areable in turn to track patient status between visitsand intervene as appropriate. Patients have moreoptions for obtaining information, advice, andcare, and are able to make better decisions abouthow to use assistance. Care resources are usedmore appropriately, reducing waste and improv-ing satisfaction for all participants.

Information management implications of con-tinuous care relationships. Such continuity ofcare requires provider-patient communication aswell as joint patient-provider information man-agement and decision support.

4. Public Accountability for QualityIn the care system of the future, care quality ismeasured, and the resulting data are available tothe public. Quality metrics are used by healthcare systems and practitioners for improvement,by employers and patients in selecting providers,and eventually, factored into compensationmechanisms. The result is a system that rewardshigh quality care.

Information management implications ofaccountability. Care quality measurement mustbe based on aggregate data analysis at the pro-vider (physician, practice, hospital, or health system) level. As it is used more in the process of delivering care, data for measurement willaccrue as a byproduct. Making such results avail-able implies posting of quality measures onpublic Web sites or other similar venues.



PROPER MANAGEMENT OF INFORMATION IScritical to the pursuit of the four principles outlined in the previous chapter, and information technology is therefore animportant contributor to improving the quality of care. A widerange of technologies in use today address the four principles.This section describes 12 different but occasionally overlappingcategories of technology or technology use, which involve themanagement of health care information.

Patient Empowerment

Empowerment requires that the patient is informed and able to make decisions about care based on that information.Technologies that empower patients in their interactions withthe health care system include: (1) those that give access to general and specific health care information as well as to the patient’s personal medical data; and (2) those that grantpatients the ability to perform data entry and tracking of theirpersonal self-management data, both for their own use and to aid their caregivers.

Personal Health RecordsDescription. The term personal health record (PHR) has a number of interpretations. In this report, it is defined as: A record that retains patient-specific health information in electronic form for subsequent direct access by the patient. MostPHRs are commercial products. Some enable the patient tocreate the record, or enter or modify elements of the record.Other PHRs are really consumer portals into provider-main-tained electronic medical records (EMRs). Some allow bothprovider and consumer to contribute data. In the case of apatient-controlled PHR, physicians can view the record if appropriate permissions are granted by the patient. TheEMR-portal PHRs are accessible by providers without patientpermission. Some products include a system of secure patient-provider email communication.

Providers find it easier to manage patient email messagesthan phone calls—for whichthey also do not get reimbursed.

IV. Twelve IT Applications

It should be emphasized that some products inthe PHR category contain considerably broaderfunctionality than indicated by this basic descrip-tion. For example, some offer population man-agement decision-support features, and healthand wellness features. Thus some PHRs fit intoboth this category and others discussed below.

Contribution to patient empowerment. ThePHR contributes to empowerment by grantingpatients access to their medical record infor-mation and permitting them to review and,sometimes, modify that information. The prod-ucts most in demand are those in which theprovider contributes most or all of the patientdata. It appears that this is because neitherpatients nor providers fully trust patient-supplieddata. Reasons for this include format of somePHRs, which resemble patient chart formats andare therefore not entirely patient-friendly, and the requirement by many products for patients tohave a certain level of sophistication in order toaccurately enter personal medical data.8

For these reasons, the systems that are tied toprovider-maintained EMRs appear to enjoy morewidespread adoption and praise. These makeaccessible to patients information about their carefrom an authoritative source (their physician orother provider), granting patients an element ofcontrol and providing a flow of information fromprovider to patient. Such applications also permitproviders to designate what data will be availablefor the patient to view. This could be perceivedas a negative feature by those who believepatients should be able to see all information atany time; on the other hand, such managementfeatures may help to avoid the scenario of thepatient discovering troubling or ambiguous dataonline, rather than learning of it first-hand froma provider who can provide explanation and sup-port as needed. That being said, early experiencesuggests that this concern may be groundless.3


This case describes the use of PHR functionality in ahigh-end electronic medical record. The applicationgives patients easy access to their medical data,plus consumer-oriented health care information andelectronic message exchange with their providers.

The Palo Alto Medical Foundation (PAMF) offerspatients access to a highly functional ehealth system, PAMFOnline, based on Epic Corporation’sMyChart application. MyChart is integrated withPAMF’s EMR, EpicCare, also by Epic. The systemshowcases three of the types of applications dis-cussed in this report: the personal health record,electronic clinician-patient messaging, and appoint-ment scheduling (discussed in more detail later).

PAMFOnline (www.pamfonline.org) gives patientsaccess to elements of their EMR data, including the problem list, medications, allergies, laboratory-test results, immunizations, and health maintenancerecord. Patients also get a link to content tailored totheir medical data, through Healthwise. In addition,they can request prescription renewals, ask ques-tions or seek advice, and request appointmentsonline through a secure messaging service.

PAMFOnline was piloted in 2001 with 1,000 patients.During this period they explored changes to thephysician workflow—which turned out to be quitemodest, thanks largely to tight integration with theexisting EMR. “That’s the strength of the applica-tion,” says Dr. Paul Tang, chief medical informationofficer at PAMF. “Electronic messages from patientsare managed in the system like any other messages—so they look just like a telephone encounter. Onlinemessaging with patients fits right in.” PAMF patientsand doctors alike are increasingly relying on the sys-tem to handle issues that do not require an officevisit and to improve post-visit follow-up; physicianscan contact patients to inquire how they are doing,and patients can reach physicians with questions.

How do patients like it? According to Tang, they particularly appreciate the convenience and unen-cumbered access to their providers. “Patients wantto communicate their needs whenever they arise,” he says. “They just expect a timely response, not necessarily an immediate one. The ability tocommunicate any time of day improves their senseof access to the health care team.” Patients also find it reassuring to have access to their medicaldata. Online health record access is not only for theyoung—15 percent of PAMF’s online patients areover age 75.

Lots of patients want to use the system. “When weannounced the general release of the system inJanuary,” says Tang, “we received 1,000 applicationsin less than a month.” Enrollment is limited toestablished PAMF patients. Because access to thesystem allows the user to see confidential healthinformation, PAMF goes through several steps to con-firm the patient’s identity before access is granted.

The practice is experiencing several new efficienciesfrom using the system. As hoped, they are seeing achange in access patterns, from telephone to onlinecommunication. Use of online communication alsoallows the practice’s advice nurse to work remotely.

Overall, the PAMFOnline experience has been over-whelmingly positive. The most important ingredienthas been integration with the EMR, says Tang. “It’s a huge success factor.”

Source: Paul Tang, M.D. Chief Medical Information OfficerPalo Alto Medical FoundationPalo Alto, California


PAMFOnline: A PHR Implementation

Patient Access to Hospital Information SystemsDescription. A subcategory of the personal healthrecord is technology that permits outpatients to obtain access to their clinical data (laboratorytest results, imaging study reports, etc.) throughonline access to hospital information systems. A number of organizations have establishedapplications that permit patients such access, andthey have begun to report their experiences.9, 10

Researchers at the University of California, SanDiego recently published the results of a trial ofphysician and patient use of a system by whichpatients access information from a hospital clinical data repository over the Internet.3 One of their concerns was how to manage patients’understanding and processing of the data, in particular, how to offer interpretation of resultsand manage patient anxiety. Their approachincorporates provider “filtering” of data—that is,grading information on a scale according to itssensitivity and appropriateness for viewing byparties other than providers. Elements includepatient selection, according to factors such as level of activity with the health system and mutual physician and patient consent; andpatient response management, such as offering a toll-free information hotline that patients can call with questions about their data. Such calls trigger a “triage” process, including contactingthe patient’s provider and offering counseling.

Contribution to patient empowerment. Thepilot study found that patients appreciated accessto their data, and none in this population suffered“information toxicity.” Physicians who used thesystem to access patient data overall found thelogin requirements somewhat cumbersome; thiswas much less of an issue in the patients’ eyes.

In general, these sites permit only selectedpatients access to the system; they limit access tosome categories of data; and they construct information/referral resources to answer patients’questions and manage their concerns. In additionall such sites must have robust security approach-es and well-defined policies and procedures safe-guarding the privacy of patient data; and thesemeasures must comply with regulatory require-ments and legislation (e.g., HIPAA).

Patient Access to General Health Information Description. Electronic access to generic infor-mation about health care topics is primarilyaccomplished through the Internet; sourcesinclude public institutions (e.g., National Insti-tutes of Health; Medline) and private companies(e.g., WebMD, Healthwise, Medscape).

Contribution to patient empowerment. Publicavailability of medical information on theInternet can help patients develop a better under-standing of their illness and treatment options—including alternate courses of therapy—and canprovide access to support communities. Havingsuch information can empower patients in dis-cussing treatment with providers and in fact alterthe balance of control in the provider-patientrelationship.

Virtually every practicing physician has someexperience with patients who have conductedextensive online research on their condition, andcome to the encounter pre-educated and expect-ing sophisticated discussion and recommenda-tions. Occasionally the patient’s knowledge of theparticulars exceeds the physician’s. Such situa-tions challenge physicians to work thoughtfullywith patients around their understanding of their condition (which may be extensive, or mis-guided) and to treat them as partners in a thera-peutic relationship.


Making the Care System

Reliable and Safe

Educated, empowered patients will increasinglydemand a health care system that performs in a consistent, safe, and dependable manner.Health system reliability is improved by the useof information systems that support the clini-cian’s information and decision-making needs.Such systems provide access to patient data,and/or medical knowledge; the most powerfulapplications provide these in combination, andoffer decision support based on patient-specificdata in the context of best practice.

Electronic Medical RecordsDescription. The electronic medical record(EMR) is a software application for ambulatorypractices whose functions include at a minimum:clinical documentation, problem list, prescribing,and result reporting.

Contribution to reliability and safety. The moresophisticated EMRs support reliability in severalways. They provide clinical decision supportfunctions, particularly the capacity to promoteadherence to guidelines in diagnosis, treatment,and prescribing.11 The safety-enhancing featuresof electronic prescribing improve reliability, andpatients’ needs are better anticipated through the use of health maintenance reminders. EMRscontribute to practice efficiency by improvingproviders’ access to clinical data, and improvecooperation among clinicians as multiple physi-cians (at least within a practice) can access thesame patient’s record for purposes of consultationor cross-coverage.

Some products include more sophisticated clinical decision-support features such as rulesengines, which can remind physicians, for example,of the need for particular health maintenance or screening interventions for certain patients,and can support practice guidelines. Productsgenerally permit the construction of standardorder sets for certain conditions. In addition mostinclude drug interaction databases to supportsafer prescribing.

In addition, some EMR applications includecomprehensive modules representing other tech-nologies, such as the PHR and physician-patientelectronic messaging (a kind of secure email). A fully integrated EMR that offers patients accessto their records and secure electronic messagingbetween patients and practitioners may be thesingle most powerful combination of existingapplications for addressing the four principles. Its strength is derived from the collection of different kinds of data in a single database, com-bined with applications that serve physician decision-making and patient-clinician and clini-cian-to-clinician communications. However, this“complete” EMR model is beyond the reach ofmost physician practices at present, both finan-cially and in terms of required clinical processchange. It is for this reason that “partial” solu-tions, described in cases throughout this report,are attractive alternatives for many practices.


Pre-Visit IntakeDescription. These applications allow patients toassemble a self-assessment and health profile in preparation for a doctor visit, for presentationto their physician. The tools guide patientsthrough an “interview” to gather a comprehen-sive medical history.

Contribution to reliability and safety. Thisapplication contributes to the accuracy and com-pleteness of the patient history. Some can alsoidentify patients appropriate for entry into dis-ease management programs. In addition, thesetools help to streamline the physician-patientencounter and make it optimally productive.

Typically, patients complete the electronic assess-ment form online from their home before theencounter. This streamlines the intake process byreducing the time spent on history gathering inthe office, eliminating or reducing the needfor the patient to fill out questionnaires in thewaiting room and answer extensive questionsfrom nursing or triage personnel. The physician may still need to ask some history questions to complement the information already gathered,but this portion of the visit can be briefer andmore focused.


Patients enjoy the opportunity to give their physiciana truly comprehensive medical history. It makesthem feel “listened to” (even if it’s through a com-puter) and gives them a sense of assurance thattheir physician is being complete and thorough intheir care.

Dr. John Bachman has been using a pre-visit intakeassessment tool from PRIMETime Medical Softwarein his family medicine practice for seven years now.The application, Instant Medical History, enablesphysicians to assemble a far more comprehensivepatient history than is usually practical during anoffice visit.

Patients complete the self-assessment—consistingof multiple-choice questions—either in the waitingroom or at home using a secure Internet site, muchthe way they fill out paper forms on a clipboard orthrough the mail. Instant Medical History uses abranching algorithm that allows it to get much moreinformation than a traditional paper form. A summaryreport in clinical language is generated for the physi-cian, with pertinent information organized by organsystem. The report can be printed for review by the physician, imported into an electronic medicalrecord, or incorporated into a messaging system tobe shared with other clinicians. In this way, InstantMedical History fits into existing workflow and

provides time-pressured physicians with a means toeasily access patients’ information and understandtheir concerns.

Bachman, who has recently completed an extensivereview of interactive history-taking with computers(submitted for publication at the time of this writing),finds that patients are more than willing to take the time to complete the assessment; almost all of his patients do so, some with help from familymembers. As for the physician, he feels that themost difficult adjustment is learning to trust thecomputer to do its job! The system excels at gettingcomprehensive information from patients, since itdoes not forget questions, and because patientstend to be more comfortable sharing sensitive infor-mation with a computer than with a person. Oncethe physician learns to trust the system, he doesn’tneed to review every piece of data, but can focuson the most important areas and on assessing thepatient’s emotional status. Bachman finds that hehas more time to listen to patients during theencounter. In addition, the application handles the lion’s share of the history documentation task,saving time there as well.

Source: John Bachman, M.D.Mayo ClinicRochester, Minnesota

Pre-Visit Assessment in a Family Medicine Practice

Inter-Hospital Data SharingDescription. Central to these schemes is thecapacity for remote access to hospital clinicaldata, from departmental systems (laboratory,radiology, etc.) or from a central clinical datarepository. The technologies are either Internet-based or rely upon secure dial-up connections.

Contribution to reliability and safety. Efficiencyis increased in several ways. Patient data are avail-able more quickly than is possible when relianton access to copies of paper records; data on apatient may even be available to a referral centerbefore the patient arrives. Quick access to recentdata may reduce the number and kinds of teststhat need to be ordered or repeated. In addition,cooperation between clinicians at the differenthospitals is enabled by these technologies. Wherepreviously the clinicians often operated as inde-pendent practitioners, data-sharing mechanismsenable organized consultation and referral amonghospitals, as well as better management of step-down care as patients are transferred from referralcenters back to the community.

Several academic medical centers have developedelectronic data exchange systems between referraland community hospitals. Data sharing within a hospital network has been accomplished in several places, including Boston’s CareGroup.CareWeb is a Web-based application that usesthe Health Level 7 (HL7) standard for clinicaldata exchange to give combined access to medicalrecords across several of the network’s hospitals.12

Sharing data across hospitals that are not part ofthe same delivery organization raises additionalchallenges. Research showed the feasibility ofsuch an approach years ago, demonstrating theuse of HL7 streams to model the exchange of aminimum clinical data set among hospital emer-gency departments, in spite of radically differentinformation infrastructures at the participatinginstitutions.13, 14

In another example of data sharing, a random-ized controlled trial examined potential benefitsof data exchange between an academic centerand two urban emergency departments. Physi-cians received both printed summaries and electronic access to patient data. The study foundthat at one hospital, but not the other, electronicaccess was associated with a decrease in chargesper encounter; the disparity between hospitalswas attributed to workflow differences. There wasno difference in the rate of hospital admission orreturn ED visits associated with electronic accessto patient data. A factor that likely limited thesuccess of the trial was significant physician discontent with the time-consuming logon andsearch procedures; this underscores the impor-tance of considering impact on workflow whenimplementing such systems.15


Care Relationships

Beyond the Encounter

Technologies that support continuous care relationships include those that enable patient-provider communication; patient access to thecare system for information, advice, and care;and provider access to interval (between visits)data and decision support.

Information for Physicians to Manage Patient PopulationsDescription. These technologies assist providersin tracking and managing populations ofpatients, especially those with chronic illnesses,according to clinical practice guidelines. Suchassistance can address several aspects of manage-ment. One is reminding providers of appropriateinterventions when the patient is being seen inthe office (often for something else); an exampleis triggering a reminder to give an elderly patient

a flu shot, even though he or she is at the officefor another illness. Another is seeking outpatients in the care population who will benefitfrom closer management, but who do not cometo the office, and drawing them into the careprocess. This can be done by screening popula-tion data for indicators of chronic disease. Athird is measuring the impact of a disease man-agement program: Are we doing a good job of improving blood sugar control in our diabeticpopulation? Data collection and analysis tools are critical to measurement.

Contribution to care relationships beyond theencounter. Technologies to assist with patientpopulation management track predictable needsof patients—either disease-specific interventionsfrom clinical guidelines, or routine wellnessmeasures for patients on an ongoing basis; andthey systematize the approach to the tracking and care of large numbers of patients.


This staff-model HMO developed an integrated datasystem to identify and track patients with chronicdisease. The system helps with outreach to patientsin need of interventions, ensures that chronically ill patients receive the care they need duringappointments, and improves care quality trackingand measurement of physician performance.

The staff physicians at the Group Health Cooperativeof Puget Sound have been using a patient registryto improve the care of patients with diabetes, car-diac disease, depression, and other chronic illnessesfor several years. The organization decided in 1992to take on the challenge of proactive populationmanagement. They started by designing “roadmaps”for the care of patients with chronic illness, incorpo-rating published guidelines, changes to visit struc-tures, physician education, and other interventions.The development of an electronic registry was a critical success factor in the adoption of theseroadmaps, according to Mike Hindmarsh, managerof clinical improvement at the MacColl Institute forHealthcare Innovation at Group Health.

The first step in creating such a registry was iden-tifying patients with chronic disease. While discus-sions around the purchase of an EMR for the entiresystem began in 1995, they felt they needed to provide information support for population care with-out delay. Group Health employed a programmerapproximately half-time for six months to write soft-ware to extract data from 12 separate informationsystems within the organization and export them to a separate patient registry database. The programuses an algorithm to screen diagnostic code data to identify patients with chronic disease, and thenextracts demographic and clinical data necessary for disease management. In addition to assembling the data in a convenient format, the application signals clinicians when one of their patients is out of compliance with a disease roadmap guideline.The application is available online to all of GroupHealth’s staff model physicians.

Source: Mike HindmarshGroup Health Cooperative of Puget SoundSeattle, Washington

Population Management at Group Health Cooperative

A simple registry along with mostly manual pro-cedures was used to collect data on patients withasthma and to encourage physician interventions.They observed that just the act of measurementproduced changes in physician behavior. The initia-tive is improving the physician-patient relationship,too, as patients feel their doctors are genuinelyinterested in how they are doing over time.

One New Jersey independent practice association(IPA) employed a patient registry as part of a strategyto use population management as a market differ-entiator in negotiations with health plans. Theirapproach holds several important lessons for man-aging workflow changes that accompany new kinds of care delivery.

The practice chose asthma management for theirfirst target. They started by collecting a single datapoint on their asthmatic patients: frequency of useof fast-acting bronchodilators, an indicator of howwell the disease is controlled. The population of like-ly asthmatics was identified by screening diagnosticcoding data; stickers indicating “registry patient”were affixed to the charts of patients with asthma.A simple survey form was developed to recordbronchodilator use at the time of a visit. Patientswere also asked to list their current medications andwhether they had been to an emergency room oradmitted to a hospital for asthma since they werelast seen at the practice. The forms were collectedfrom all practices by a data entry person, and theinformation entered into a computer registry(CarePlanner, by DocSite, LLC).

Data capture was spotty at first; only one asth-matic in four was asked the screening questions.(Patient capture was up to about 50 percent as ofApril 2002.) From these initial inquiries, the organ-ization discovered that 42 percent of their asthmapatients were poorly controlled (about the nationalaverage!). But they also observed that just theprocess of asking about control prompted a changein physician behavior: In 76 percent of cases where control was inadequate, the doctor initiated a change in the patient’s medical regimen toimprove control.

As provider-specific reports on patient disease control and physician prescribing behavior are gener-ated from the registry, Dr. Jim Barr, the IPA medicaldirector, meets with each physician and his or herclinical coordinator nurse, and they work together todevise interventions to improve control within the physician’s asthmatic population. The specificapproach to intervention, such as outreach topatients, is left to individual practitioners and theirclinic staff.

Work with community employers has proven instru-mental to the group’s success. When health plansbalked at giving the group more favorable contractsbased on their disease management efforts, Dr. Barrdiscussed his predicament with local employers—who subsequently persuaded the plans to rethinktheir position and grant the desired contracts.Pressure from employers was also critical in con-vincing local laboratories and health plans to sharepatient data electronically with the practice in orderto facilitate disease management of diabetes, thegroup’s next target diagnosis. The registry in turnassists the practice with the production of HEDISperformance data for plans and employers.

Perhaps most important, Barr believes the organ-ization’s population management program has beenimportant in strengthening physician-patient rela-tionships. “Patients like the fact that physicians areutilizing the registry system to more closely monitortheir disease state,” he says. Future plans includebroader automation of the registry and provision of a Web interface through which individual prac-tices will be able to enter their own survey data asthey collect it.

Source: Jim Barr, M.D.Central Jersey Physician Network, LLCFlemington, New Jersey


IPA Uses a Patient Registry to Manage Asthmatics

Several kinds of technologies support populationmanagement, all providing population type views(overview of all patients in a given populationgroup—for example, hypertension) as well aspatient-centric views of data. At the most basiclevel, populations can be tracked using simplespreadsheets on a PC; at a more advanced level,data can be imported electronically into the system through interfaces. The most sophisticatedapproach incorporates the population manage-ment application into an EMR; such integrationautomates much of the data entry involved intracking patients. Applications must be pro-grammed to provide information on past inter-ventions and schedules for future interventions.

All applications for population managementrequire significant up-front labor to configurethem and to populate them with baseline data.Simpler (e.g., PC-based) applications need to beintroduced into practice workflow in a systematicway: Elements include pre-printing of population-or patient-specific sheets to remind practitionersof interventions due during visits; processes for insuring that patient data are updated in theapplication as they are received; and periodicanalysis and quality assurance tracking of the fullpopulation base. More advanced applicationsmake some of these tasks easier, but practicalallowances must still be made to insure that theapplication’s functions (e.g., electronic reminders)fit into and do not disrupt workflow, otherwisethey will not be used by clinicians.

Patient-Physician Electronic MessagingDescription. Electronic message exchangebetween patient and physician can occur in manycircumstances and through a variety of technol-ogy applications—from “standard” email with noparticular security or encryption safeguards, tospecialized secure messaging systems provided bycommercial products or developed by hospitals,to messaging systems associated with EMR and PHR applications. A great deal has beenwritten on the topic of physician-patient email,including a recent research report for the Cali-fornia HealthCare Foundation.16 This section willbriefly summarize some of the critical issues.

Contribution to care relationships beyond theencounter. The asynchronous nature of electronicmessaging allows patients and physicians to con-tact each other whenever the need is felt, and attheir own convenience. Patients appreciate theimproved access to the physician. Physiciansappreciate the improved efficiency; many find iteasier to answer patient queries between tasksthroughout the day, reducing the number ofhours they spend on the phone. The self-limitednature of electronic messaging helps control the scope of the exchange, which is much more difficult to do with telephone calls. Electronicmessaging is also self-documenting, an improve-ment over phone contact.


This case describes the start-up of a physician-patient electronic messaging initiative in a primarycare network. The leaders had to manage physicianreluctance, and providers are starting to enjoy someof the efficiencies of asynchronous communicationwith patients.

Physicians in a primary care network affiliated with the University of California, Davis have beenpiloting electronic messaging with patients sinceNovember 2001, using a secure messaging systemfrom Healinx Corporation. Located in one of thecountry’s high-technology centers, the practice wasexperiencing demand from tech-savy patients forelectronic access to providers. In addition, the prac-tice’s phone system was heavily leveraged: Patientswere experiencing long telephone waiting times,and practice administrators wanted to reduce waitsand relieve the burden on the phone banks.

Eric Liederman, MD, medical director of clinicalinformation systems, was a central player in thedecision-making process. A product integrated intoan EMR would have been their first choice, but the organization was several years out from beingready to implement an EMR, and they didn’t wantto wait that long. In considering the alternatives for providing electronic access, the group deter-mined that security, message capture, and archivingwere top priorities. The Healinx product addressedthese requirements, as well as providing messagetemplates and the ability for patients and physiciansto view and modify lists of problems, medications,and messages.

Initially seven physicians and one nurse practitionerused the system to communicate with about 300patients. As of April 2002, four more physicians, andanother 250 patients were added; and the networkis preparing for broader roll-out to its other groups.All patients in participating practices are allowed torequest an electronic access account, but physicianscan turn down such requests by patients for whomthey feel the medium would be ill-suited to manag-ing their relationship. Access can be revoked incases where a patient’s behavior proves inappropri-ate or difficult to manage.

At the outset some providers raised concerns ofbeing overwhelmed by unmanageable quantities ofpatient messages, and of losing revenues by pro-viding “free care” online. The first of these turned out not to be an issue; in fact, one provider foundherself able to leave work earlier, due to fewer tele-phone calls, and to answer patient messages fromhome in the evening. Likewise, the concern aboutloss of revenues has not been borne out. Rather,providers find it easier to manage patient email messages than phone calls—for which they also do not get reimbursed.”With electronic messaging,physicians are in complete control of their time.That’s not true on the telephone,” says Liederman.

While Healinx enables providers to charge patientson a per-message basis, the organization has chosen to hold that option in reserve, only to beused for volume management—if for example, apatient were to start sending numerous unnecessarymessages. So far there has been no need to chargeany patients.

Given the small scale of the initial pilot, it has notbeen practical to this point to attempt to measurechanges in telephone use or other impact on thepractice, although a patient satisfaction survey is being readied for use now. As the application isrolled out more widely Liederman plans to gathermore such performance data.

Ultimately Liederman sees messaging as one stepalong the road to implementation of a full EMR withpatient access. But for most practices that cannotafford to, or are not ready to, implement highly integrated EMRs, he sees electronic messaging as a huge opportunity to improve patient access andpractice efficiency.

Source: Eric Liederman, M.D., M.P.H.Clinical Information SystemsUniversity of California, Davis Health System


E-messaging at UC Davis

Patient Access to Tailored MedicalInformation, Online Data Entry, and TrackingDescription. These applications give patientsinformation that addresses their medical condi-tion in the context of their personal clinical data(e.g., blood glucose level, weight, or blood pres-sure). They include online “disease management”applications, which permit patients to obtain specific medical reference information on theirdisease, and to track their management of theircondition (e.g., blood sugar control in diabetes)online using data-entry and trending tools. The results can be made available to physiciansto assist them in patient monitoring.

A number of disease management companiescarve out a full range of services, providing theirown clinicians and managing patients directly;since these companies’ primary contributiondepends at least as much on their clinical man-agement model as on technology, they arebeyond the scope of this report. The generaltopic of disease management is considered indepth in another report in this series.17

Contribution to care relationships beyond theencounter. These technologies support patientself-care as well as provider monitoring and sup-port of care between office visits. Patient needsare better anticipated as a result of ongoing trenddata available to patients and providers. Providersare able to monitor patients’ progress at theirconvenience, and having trending data regularlyrecorded and easily available also facilitates anefficient office visit.

The greatest impact of this technology is on the patient’s self-care experience. Patients are pri-marily responsible for entering their personaldata into the application on a regular basis. Thismay help to draw them more actively into themanagement of their own disease.

Online SchedulingDescription. Through these applications, patientsare able to connect with a practice over theInternet and schedule appointments. In mostinstances, practices manage online scheduling byaccepting patient requests for appointment times;the practice administrator then examines theschedule and responds to the request with a confirmation or alternative appointment. Onlinescheduling may also occur within a health sys-tem, with physician practices using the system toschedule patients for outpatient procedures.

Contribution to care relationships beyond theencounter. Online scheduling improves the care relationship by facilitating access to care,reducing the time and inconvenience—particu-larly from the patient’s point of view—of the traditional appointment scheduling process.


A software system that downloads blood glucosemeasurements from patients’ glucometers, and permits tracking and trend display and analysis is revolutionizing the management of diabetes at thisendocrinologist’s practice.

Monitoring patients with chronic disease is literally afull time job for Tim Bailey, M.D., an endocrinologistat the University of California, San Diego. “Over half of my patients have diabetes,” says Bailey,“and diabetes is a disease with lots of data, and lotsof targets for management. Insulin managementrequires analysis of patterns of data, not just a fewdata points.” Monitoring patients’ blood sugar con-trol generates from one to four data points per day, every day, for each patient; and this doesn’tinclude other labs (HbA1c, liver functions, creatinine)or physiologic parameters like patient weight andblood pressure.

Eight months ago, Dr. Bailey and his partner beganusing iMetrikus’ Medicompass system. It is apatient registry for diabetes management, allowingthe physicians to capture and track the relevantdata, display it graphically, and screen their patientpopulation for individuals who would benefit from anintervention. A unique feature of the system is auto-mated capture of patient monitoring data. Patient-measured glucose levels are downloaded from the patient’s glucometer (which has a memory) tothe iMetrikus system; depending on the device and frequency of blood sugar checks, patients can store and download from one to six months’ data at a time.

Downloading can be done when the patient arrivesat the clinic; but increasingly, patients are submittingthe data from home, using a portable device thatsends the data to the Medicompass system bysecure dial-up connection. The remainder of thedata must be hand entered by administrative staff,with the exception of lab values from one particular reference lab, which provides an electronic feed.Patients can also view their data online usingiMetrikus’ patient portal, myhealthchannel.com.

After eight months, Bailey estimates that about 95percent of his diabetic patients are in the system.Consistency of data capture has been steadilyimproving. Bailey also encourages patients to entertheir medications into the system, preferably inadvance of their visits; this saves valuable time dur-ing the encounter and helps to keep the registry up-to-date.

The principle value of the system so far has beenthe capture and graphic display of patient data foruse during the clinic visit. As more data are capturedover time, the outreach value of the system willcome to the forefront, enabling better identificationof patients who need care interventions. The physi-cians are also able to evaluate patients’ adherenceto their monitoring regimens. Finally, the systemfacilitates report generation for payers and otherswho request population data on patients.

How do patients feel about the system? At first itwas relatively transparent to them; but as they havebegun to see how it aides physicians in trackingtheir progress between visits, and have started tosend in data themselves from home, it seems togive them a sense of security that someone is pay-ing attention to them even when they are not in thedoctor’s office.

While it’s too early to formally evaluate the system’sperformance, Bailey is confident that Medicompassis helping him improve care for diabetic patients. Hisenthusiasm has led him to work with iMetrikus toassist other users with the system and to offer con-sulting advice as the product is further developed.

Source: Tim Bailey, M.D.University of California, San Diego


Electronic Capture of Patient Self-care Data

Computer-Assisted Telephone Triage and AssistanceDescription. Various models of call center tech-nology have been used to improve communica-tions between patients and their caregivers. Themost advanced centers are staffed by both trainedcustomer service representatives (CSRs) andadvice nurses, the latter backed by physicians,and are capable of a range of service, includingappointment booking, prescription refills, dis-pensing medical advice (guided by protocols),and provider messaging. CSRs and advice nurses

are assisted by computer-telephony integration—technology that presents patient informationincluding demographics and medical records assoon as the patient calls. Online advice protocols,appointment guidelines, and scheduling and registration systems are also available to assist thepatient with a wide range of options and infor-mation. Messages can be sent automatically to apatient’s physician, triggered by specific events(such as new prescription requests, patient requests,or according to special provider instructions).


Implementing centralized scheduling of proceduresusing an automated system can serve as a first stepto opening access to care.

McLeod Regional Medical Center implemented anapplication by Scheduling.com, to address mountingdissatisfaction with this aspect of access to care.McLeod had been receiving a number of complaintsfrom both physicians and patients—earliest slots forprocedures were often a month out and wait timesonce at the health system could reach three hours.

With this application, physician offices call in throughan automated phone system to the schedulers, pro-viding the patient’s name, date of birth, and socialsecurity number. A number of algorithms built intothe scheduling process ensure efficiency and safety.For example, the system takes into account thetime required for a procedure in addition to traveltime between locations, so the patient cannot bescheduled for back-to-back procedures in departmentslocated 20 minutes apart. If the patient is beingscheduled for a radiology exam, the scheduler isprompted to ask if the patient is pregnant, to ensurethat the appropriate procedure is ordered and thatthe technician is prepared for any special needs.

The move to centralized scheduling across thehealth system, serving more than 300 physicians,required a number of changes in office workflow. Theneed to provide schedulers with patient data neces-sitated obtaining the patient’s chart before callingthe central scheduling facility; this in turn requiredchanges in the routing of records in the office. Theorganization soon plans to implement a physicianportal that will allow practices to schedule proceduresonline themselves. McLeod also plans to implementa consumer portal that will enable patients torequest appointments from the McLeod Web site.

Since moving to online scheduling, patients areseen sooner, they can choose the most convenientfacility, and wait times are down. McLeod has beenable to increase capacity by more efficiently fillingexisting slots as well as by opening up new timeslots as efficiency has grown.

Source: Lesli KennedyDirector of Reservations and SchedulingMcLeod Regional Medical CenterFlorence, South Carolina

Centralized Scheduling of Medical Center Procedures

Contribution to care relationships beyond theencounter. Advice and appointment call centersprovide access to specific medical advice and self-care information and appointment scheduling,and are a more convenient avenue of commun-ication with the provider compared with callingand leaving messages at the office.

Public Accountability for Quality

Online Access to Provider Performance DataDescription. Some regulatory bodies, state gov-ernments, and private companies provide publiconline access to various kinds of physician andhospital performance or quality data. Examplesinclude hospital rankings according to Medicaredata on outcomes or practices, and state Boardsof Medicine providing physician licensure anddisciplinary action online.

Many types of information are being made accessible through the Web, and the quality andutility of these data vary dramatically. At leastone state Board of Medicine18 makes availablehistorical data on registered physicians, includinglicensure status, medical school and training,whether any disciplinary actions have been takenagainst the physician, and whether the individualhas made a payment on a malpractice action inthe last five years.

Several factors must be taken into account inweighing the value of providing quality data tothe public. One factor is the nature and reliabilityof the data, which is (not surprisingly) hotlydebated. Another, perhaps more important, factoris the curious lack of impact of such data on con-sumers’ selection of providers. The latter equationmay change as employer groups have recentlytaken a keen interest in care quality measures,and are planning to influence their employees’choices of providers accordingly.

The Leapfrog Group is the primary employer-based coalition targeting care quality improvementat present. As of mid-2002, this health care pur-chasing coalition has more than 100 corporatemembers who collectively purchase benefits forapproximately 31 million Americans. The organi-zation is committed to improving patient safetythrough the use of market incentives. In Novem-ber 2000 they announced their intention to targetthree specific quality improvement standards: use of computerized medication ordering in thehospital to intercept dangerous medicationorders; coverage of intensive care units by inten-sive care-trained specialists; and referral to high-volume hospitals for certain surgical procedures.The group issued a voluntary survey to hospitalsto evaluate their current level of adherence tothese standards and is posting the results on theirWeb site. In the near future hospitals with com-puterized physician order entry will be asked totest their systems for adherence to the Leapfrog standard using a specific methodology, with theresults posted for public view (see sidebar). The Leapfrog Group will encourage employees to consult these results in selecting their careproviders; and it is likely that provider contract-ing patterns will begin to be affected as well.



This standard for physician order entry is unusual inseveral regards. Not only does Leapfrog call for hospitals to adopt a specific technology to reduceadverse drug events; they also request that eachhospital report publicly the results of a Web-basedevaluation of their system’s effectiveness at block-ing ADE-causing errors.

The automated, self-administered test requires eachhospital to download from the Leapfrog Web site aseries of “test patients” to be programmed intotheir CPOE testing environment. They then down-load a series of test orders to be entered into thesystem, against the test patients; they are generatedat random from a large master order set, and repre-sent 12 categories of dangerous orders (e.g., drug-allergy, drug-drug interactions, etc.). The hospitalrecords the system’s response to each order, and

reports these results back via the Web site. TheWeb-based evaluation system contains a scoringalgorithm that calculates a weighted score for eachorder, depending on the severity of any error inter-cepted (or not). In addition to public posting of anaggregate score on the Leapfrog Web site, the hospital taking the test receives detailed feedbackon how their system performed in each category oferror interception/quality improvement. This infor-mation serves to guide the hospital in designingimprovements to their CPOE system, which shouldimprove its safety performance.19

Source: Peter Kilbridge, M.D.First Consulting GroupLong Beach, California

The Leapfrog Group’s Standard for Computerized Physician Order Entry (CPOE)


THIS REPORT HAS REVIEWED SOME TECHNOLOGYapplications in use today that can contribute meaningfully tobridging the health care quality chasm. But technology cannotbe successfully implemented without consideration of organi-zational context. This section discusses some categories of organizational issues—including workflow, cost, and culturechange—that must be managed if a new technology is to contribute optimally to improved quality of care.

For some applications, enormous organizational and workflowchange must occur before a technology can be implementedeffectively. This is particularly true for access to care applica-tions, especially online scheduling. Traditional access to care ispractice- and physician-centric, as opposed to patient-centric;physicians are loathe to give up control of their schedules. A typical office schedule has almost all of its appointment slotsbooked before the office opens for the day, making it difficultfor patients to be seen quickly. Opening access requires that anumber of changes in the management of patient visits beundertaken, and physicians must be willing to relinquish con-trol of some aspects of their schedule. Approaches include an emphasis on team-based care, which improves the use of physicians’ time; better ongoing management of patients withchronic disease; and changes in the types of appointmentblocks scheduled to free up a larger number of visit slots eachday. These changes can make it possible to see more patientson shorter notice, and permits greater flexibility to meet specific patient requests.

While redesigning access to care is hard work, it has been successfully accomplished at several organizations.20, 21, 22, 23

In cases where a full redesign and direct online scheduling isnot possible, managing appointment requests via electronicmessaging is a viable option. The lower level of organizationalchange required to accomplish this is within the reach of many practices. The principle requirement to achieve suchchange is committed leadership.

The principle requirement toachieve such change is committedleadership.

V. Organizational Challenges

Implementing a highly functional EMR presentsanother obstacle: cost. High-end EMRs aredesigned for medium to large practices, and theircosts are prohibitive for many smaller ones.Implementation of these systems also requires amoderate to large amount of change in workprocess; clinician practice patterns are greatlyaffected, especially those related to clinical documentation and intra-office communication.Other approaches that achieve elements of thefunctionality of the EMR (such as electronicmessaging within a secure application) can beachieved at lower cost, and with more modestchanges to workflow.

Large call center systems, while ultimately veryefficient, are also expensive to implement. Theyare therefore most attractive to large organiza-tions that can finance such projects, and whereeconomies of scale, once realized, can generatesignificant savings.

The third type of obstacle to change—cultural—is well illustrated by the case of remote electronicaccess to hospital data for patients or physicians.Hospitals are reluctant to grant remote access topatient data, particularly to patients themselves;several of the concerns have been discussedabove. Other hurdles—technology and manage-ment—are less significant than the cultural and cost barriers. This will likely change, as thepioneers continue to publicize their successes,more affordable products are developed, and con-sumers begin to expect access to their medicalinformation as a matter of course.

Electronic messaging between physician andpatient also raises cultural issues. Many physiciansare fearful that patients will fail to respect thelimitations of the medium and use it inappropri-ately. If electronic messaging is to be adopted byproviders, patient use of the technology must be proactively managed. Much has been writtenabout this; the following are some of the factorsrequiring attention:

� Email is not appropriate for urgent problems,and patients must be educated to this effect.

� There is the possibility that the physician maynot be able to respond quickly. Patients mustbe advised to move to other modes of communi-cation in a timely manner if the issue warrants.

� Email outside of specialized applications is not secure—employers can read employees’email sent on company networks, and thelegal precedent supports their right to do so.

� Some providers worry about legal ramificationsof advising patients online. For this reason,many physician users restrict email exchangeto follow up of known problems for which thepatient has already seen the physician.

� Some physicians fear a deluge of patient mes-sages that would be unmanageable. Experiencehas generally shown that this fear is unfounded,if care is taken in educating and obtainingconsent from patients.24


Another concern sometimes voiced by cliniciansis potential loss of revenues if such communica-tions are not reimbursable. It can be argued that physicians already spend large amounts ofunbillable time on the telephone answering questions from patients. Further, electronic mes-saging has been found by some providers to beconsiderably more efficient and less time-con-suming than phone communication. None-theless, these concerns have prompted at leastone electronic messaging mail company to offerthe option of charging patients for each contactwith their physician;25 and several health plans are now offering reimbursement to physicians for electronic messaging “encounters” withpatients.26, 27, 28 Such willingness indicates thatsome health plans are coming to see electronicmessaging as a cost-effective adjunct, or alter-native, to traditional encounters.

Practices that offer disease and wellness manage-ment applications will need to change their prac-tice culture from the reactive “siege” mindset inwhich so many physicians are trapped today, to amore holistic, proactive management philosophyand style. This is a challenging transition inmany practice environments where clinicians areworking long hours and struggling to keep up.Here again, educated and enlightened leadershipis required, and the transition will be easier insome practice environments than others.

The movement to provide better access toprovider performance data faces yet another setof challenges—largely political, but also scientificand educational. Provider associations generallyoppose public release of performance data, on thegrounds that such data are in some way inaccu-rate or misleading, or will lead to an onslaught oflitigation, which will suppress reporting and hobble quality improvement efforts.7 Beyond thedefensive aspects of such objections, they holdsome truth; indeed, much of the informationcurrently available to consumers is problematicand may be misinterpreted. Thus, daunting challenges remain—not only in determiningwhich measures of quality are most viable, andhow to obtain, interpret, and present them, butin educating consumers about why some data are valuable and others not.



THIS REPORT HAS ILLUSTRATED THAT A VARIETYof technologies, many of which have come into use fairlyrecently, can meaningfully contribute to improved care quality,as defined by the principles of patient empowerment, reliabilityand safety, continuity of care relationships, and public account-ability. These tools can be used by many organizations todayto improve all aspects of care for their patients. Organizationalissues must be dealt with; indeed, with the exception of theEMR and call centers, change management represents a greaterbarrier to adoption than does cost. But as our case studies andexamples from the literature illustrate, such barriers can beovercome with adequate leadership commitment.

Many aspects of the current, evolving health care environmentwill support and encourage the adoption of such improvementtechnologies and facilitate the organizational changes required.Consumers are becoming more actively involved in their care;this trend is certain to continue, and will go a long way towardovercoming the cultural and political barriers that have beendiscussed. Employers—particularly the Leapfrog Group—aredemanding adoption of technology to support quality, and willlikely further expand their standards to encompass additionalaspects of quality and patient safety. Increasing regulatoryattention to safety and quality will increase the pressure toadopt technology to support these objectives.29, 30, 31 Indeed thethird report in the IOM series on care quality suggests the likely measures of quality whose reporting will be required ofprovider organizations in the near future.32 And as the casespresented here illustrate, there are plenty of examples of earlysuccesses among those pioneers who have chosen to use tech-nology as well as process innovations to begin to cross the quality chasm.

VI. Conclusions

Endnotes

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. NationalAcademy Press, Washington DC, 2001;3.

2. Ibid Pp. 8-9.

3. Masys, Daniel, et al. 2002. “Giving patients access totheir medical records via the Internet: the PCASSO experience.” JAMIA 2002;9;181-191.

4. Kilbridge, Peter, M.D., and D. Classen, M.D. A Process Model of Inpatient Medication Management and Information Technology Interventions to ImprovePatient Safety. 2001 Research Series, Volume 1, VHA.

5. Institute for Safe Medication Practices. “A Call toAction: Eliminate Handwritten Prescriptions Within 3 Years!” (http://www.ismp.org/MSAarticles/Whitepaper1.html).

6. Kilbridge, Peter M.D. E-Prescribing. CaliforniaHealthCare Foundation, November 2001.

7. Brennan, Troyen M.D., J.D., M.P.H. “The Institute ofMedicine report on medical errors—could it do harm?”NEJM 2000;342:1123-1125.

8. Kim, M.I. and K.B. Johnson. “Personal health records:evaluation of functionality and utility.” JAMIA2002;9:171-180.

9. PatientSite application at CareGroup, Boston (www.caregroup.org/patientsite.asp).

10. Cimino, James M.D., et al. “Architecture for a web-based clinical information system that keeps the designopen and the access closed.” Proceedings of the 1998AMIA Symposium, p. 121-125.

11. Metzger, Jane. Clinical Decision Support Tools for theSmall Physician Practice. California HealthCareFoundation, 2002 (in press).

12. Halamka, J.D. and C. Safran. “CareWeb, a web-basedmedical record for an integrated health care delivery sys-tem.” Medinfo 1998;9:36-39.

13. Kohane, I.S., F.J. van Wingerde, J.C. Fackler, et al.“Sharing electronic medical records across multiple heterogeneous and competing institutions.” ProceedingsAMIA Annual Fall Symposium 1996:608-612.

14. van Wingerde, F.J., J. Schindler, P. Kilbridge, et al.“Using HL7 and the World Wide Web for unifyingpatient data from remote databases.” Proceedings AMIAAnnual Fall Symposium 1996:643-47.

15. Overhage, J.M., P.R. Dexter, W.H. Cordell, et al. “A randomized, controlled trial of clinical informationshared from another institution.” Annals of EmergencyMedicine 2002:14-23.

16. MacDonald, Keith, J. Case, and J. Metzger. E-Encounters. California HealthCare Foundation,Oakland, CA: November 2001.

17. LeGrow, Greg and J. Metzger. E-Disease Management.California HealthCare Foundation, Oakland, CA:November 2001.

18. Massachusetts Board of Registration in Medicine(www.massmedboard.org).

19. Kilbridge, Peter, E. Welebob, and D. Classen.“Overview of the Leapfrog Group Test Standard forComputerized Physician Order Entry.” The LeapfrogGroup and First Consulting Group, November 2001.

20. Murray, Mark, M.D., M.P.A. and Catherine Tantau,B.S.N., M.P.A. “Same-day appointments create capacity,increase access.” Executive Solutions for HealthcareManagement, February 1999.

21. Lippman, Helen. “Same-day scheduling.” Hippocrates,February 2000, 49-53.

22. Simmons, Janice. “Striving to provide more efficientcare in the outpatient setting.” The Quality Letter forHealthcare Leaders, Vol. 12, No. 10, October 2000, 1-12.

23. Grandinetti, D.A. “You mean I can see the doctortoday?” Medical Economics, March 20, 2000, 102-114.

24. Kane, B. and D.Z. Sands. “Guidelines for the clinicaluse of electronic mail with patients.” The AMIAInternet Working Group, Task Force on Guidelines forthe Use of Clinic-Patient Electronic Mail.” JAMIA 1998Jan-Feb;5(1):104-11.

25. Healinx Corporation (www.healinx.com).

26. Baldwin, Fred. “Will pay for email,” e.MD, Fall 2000,21-23.

27. Appleby, Julie. “Insurers, doctors ponder implications ofe-consultations,” USA Today, March 26, 2001.

28. Carrns, Ann. “In effort to boost health care quality,employers urge doctor visits by email,” Wall StreetJournal, March 23, 2001.

29. California Senate Bill 1875; www.leginfo.ca.gov, 1999-2000 legislative session.

30. United States Senate Bill S. 2590, the Patient Safety andQuality Improvement Act, introduced June 2002.

31. United States House of Representatives Bill H.R. HR4889, the Patient Safety and Quality Improvement Act(House version), introduced June 2002.

32. Institute of Medicine, “Envisioning the National HealthCare Quality Report.” National Academy Press,Washington DC. 2001.


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