The Challenges of Population Health Management

The United States has the most advanced health care in the world. There are gleaming medical centers across the country where doctors cure cancers, transplant organs and bring people back from near death.

But a poll conducted by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health shows that only one-third of Americans say the health care they receive is “excellent.” Even fewer people are impressed with the system as a whole.

“When you’re talking about health care, we have this amazing kind of schizophrenia about our system,” says Dr. Georges Benjamin, executive director of the American Public Health Association.

The split in thinking shows up in the poll numbers.

Much the way people hate Congress but love their own representatives, people like the care they receive while complaining about the system. About 80 percent say they get good or excellent care. But 42 percent rate the health care system in their state as fair or poor.

You can find the detailed results of the national poll here and results on how income affects health care here.
Results for the individual states:
Florida
Kansas
New Jersey
Ohio
Oregon
Texas
Wisconsin
“We deliver the best medicine and nursing on the planet, no question about it. But it requires a lot of things,” Benjamin says.

Things like an insurance card, filling out lots of forms, paying copays and deductibles, and running from doctor to lab to imaging center.

The system is wildly complex and hard to navigate, and can be very frustrating. Benjamin says it’s this process of getting health care that people hate.

Just ask Cheryl Vaun, one of our poll respondents.

The 57-year-old from Albany, Ore., has a low opinion of the health care system after spending years trying to help her daughter who fell suddenly ill as a teenager.

The 16-year-old gained 30 pounds in about a month. She had migraines and her muscles would seize up in pain.

Vaun and her daughter went from doctor to doctor repeating the same tests and procedures. When doctors couldn’t figure out what was wrong, they offered Vaun’s daughter antidepressants.

“We were pretty upset,” she says. “My daughter was devastated because obviously she’s suffering all of these health issues and it was a bit terrifying.”

Vaun’s daughter was finally diagnosed with acute anemia.

If the problem had been caught earlier, Vaun believes her daughter could have recovered. Instead it has become a chronic condition that leaves her tired and weak. The treatment is iron pills or injections, which are hard on her system and leave her sick to her stomach.

Repeat tests, multiple doctor visits and lack of results erode people’s faith in their care, says Sarah Dash, vice president for health policy at the Alliance for Health Reform in Washington, D.C.

“Health care hasn’t always been designed with the needs and efficiency of the patient in mind,” Dash says. “It’s designed for the various doctors and the health care system.”

The poll, conducted from September to November, also shows that quality of care can depend heavily on a patient’s income.

Adults with incomes below $25,000 a year are about three times as likely as higher income people — 34 percent versus 13 percent — to say the health care they personally receive is only fair or poor.

William Dale Coger, 52, is one of them. The carpenter from Oak Hill, W.Va., says he’s been unable to get help for his back, which he injured about 15 years ago while hauling pipe out of a well on his property.

His pain, mild at first, has gotten worse over the years. These days, he struggles to get out of bed in the morning and finds his left leg is unstable and his left foot goes numb.

“It’s gotten to the point that this pain travels clear up my back into my shoulder blade into my left side of my neck and gives me migraine headaches sometimes into the left side of my head,” Coger says.

He’s on disability and Medicaid.

Coger sees doctors at a local clinic, but he says they don’t take his back trouble seriously. They recommend exercise and offer ibuprofen. He thinks surgery would be able to help him but says doctors at the clinic refuse to order an MRI.

“I want to be cured,” he says. “I don’t want pills. I don’t like pills.”

Benjamin of the APHA says Coger and his doctors don’t seem to have the same goal. They’re managing his pain; he wants to get back to work.

“It can be really frustrating if you don’t understand the end goal of your care,” Benjamin says.

Dash says the Affordable Care Act includes lots of pilot projects to improve how patients get care — and to make it cheaper. But those changes come slowly in a system that today is wildly complex.

And for most people, the law seems to have changed little.

The NPR poll shows 74 percent of people believe their health care has stayed about the same since the ACA was implemented. And for the minority who’ve seen a change, about 14 percent say their care is better while 9 percent say it’s worse.

And most think the law has had no direct impact on them.

Even if they didn’t buy a plan through the exchange, people have more insurance benefits than they did before. They get free screenings like mammograms and colonoscopies. Birth control is free. And they can still buy insurance even if they have a pre-existing medical condition.

Most people aren’t aware of that, though. Our poll shows only 1 in 6 adults think their benefits have increased in the past two years, and 12 percent believe they’ve declined.

And many people still don’t like the law.

Ivan Rivera, 29, from Miami, says he is opposed to Obamacare and is angry that he’s required to get insurance.

He says he works hard, takes care of his own health and doesn’t want to have to subsidize coverage for others.

“We’re paying for other people,” he says. “People that are not working. People who are not pulling their own weight.”

Many Dislike Health Care System But Are Pleased With Their Own Care

Besides technology considerations, any initiative must include a cultural shift by both providers and patients. Proactively addressing public health is the driving force behind population health management. More than simply delivering better care, today’s providers are looking for ways to reduce the need for reactive interventions such as emergency department visits, hospitalizations, and readmissions, which often address undetected—and therefore untreated—medical issues that can significantly drive up the cost of health care. It’s a noble goal, but is it realistic? How can health care organizations reach such heights without busting their budgets?

There are many facets to population health management. Technological barriers need to be overcome and costs must be taken into account. Perhaps the biggest challenge, however, lies in changing the way people think about health care. “It’s not episodic. It’s trying to take a more broad view and get beyond a single episode of care,” says Ty Tolbert, vice president of solutions for Wellcentive, a provider of tools and services that support population health management. “It’s a methodology.” Know Thy EHR Tolbert says the most basic components of the methodology are data. Health care organizations must have the ability to collect, aggregate, and analyze data. Rather than the retrospective data that traditional health care relies on to guide clinical episodes, population health management attempts to determine which patients can benefit from preventive interventions to potentially avoid a clinical episode. These initiatives can take the form of national programs, such as the physician quality reporting system (PQRS), regional programs, programs run by insurance companies, or programs developed by the providers themselves. The first step toward any type of population health initiative is to understand the types of data necessary to meet the organization’s needs, Tolbert says. He adds that organizations often think they need as much data as they can collect, but that’s not necessarily true. For example, PQRS requires data from minimal sources. Also, with data often stored in multiple EHR systems, it’s important for organizations to know what types of data are standardized across multiple systems. “In a primary care multispecialty group practice, you need to be able to see the medical record to know what’s happened to that patient, not just what happens specifically inside of the ambulatory care environment that you as a practitioner manage, but what happens outside of your environment,” says Bob Dichter, a senior director of project management for NextGen Healthcare, an EHR provider. “What happens with the patient in their home? What happens to the patient with their specialist? What happens to the patient in the hospital? The groundwork is whether you are able to access your data from multiple sources.” Connecting the wires between multiple care providers, which is only part of the equation, is no easy task. Once the data are aggregated, they need to be analyzed. Dichter says analytical tools can help providers better understand how their services are being utilized and identify gaps in care to locate at-risk patients. Analytical tools also help to identify the types of data that must be reported for population health management programs. Evaluating the data requirements for various programs can be daunting. Tolbert says regional programs may be easier to participate in than PQRS and may provide financial incentives for participation. However, there is a good deal of variability among regions. He recommends that health care organizations do their homework to find out what’s available and begin their data collection process with a question: What outcome are we trying to achieve? For example, the organization may want to target its efforts toward patients who are the most likely to be readmitted. A targeted approach allows health care providers to determine their priorities and use their resources more efficiently, Tolbert says. Many programs use benchmarks related to common conditions, such as diabetes and heart disease, to measure participants’ effectiveness in meeting population health goals. To track benchmark data, many EHR software providers have developed a registry function that allows health care providers to measure their performance against national standards. Registries are a vital part of population health efforts, says David B. Nash, MD, MBA, the founding dean of the Jefferson College of Population Health and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at Thomas Jefferson University. HIM and other medical records professionals are likely to play a key role in registry management, Nash says. “These registries are going to be the heart and soul of population health delivery, and someone is going to have to manage these registries,” he notes. “The doctors will be the utilizers, but I envision that [HIM and medical records professionals] will be very involved in a deeper understanding of the registry function.” Pay Now or Later Upgrading technology, such as implementing EHRs and developing interfaces among multiple systems, typically requires a significant up-front investment. Hiring the necessary additional staff and changing business processes are part of that cost. Looking at the long-term picture, however, technology upgrades could very well save money. In fact, Dichter says many health care providers include time saved as part of their value calculations, noting that improved methodology—in the coding department, for example—can boost workflow and improve the quality of care. Tolbert adds that once data are aggregated, it’s fairly simple to calculate a return on investment on various population health initiatives. He says, generally speaking, costs are minimal compared with benefits. For example, an organization that Wellcentive worked with saved $8 million in PQRS penalties and earned an additional $8 million in incentive payments from a Blue Cross Blue Shield pay-for-performance program. Besides generating revenue now, Tolbert says implementing a population health initiative can stave off future penalties. “With a lot of these initiatives, most of them only have the upside available. In other words, you’re only going to be able to make money or maybe a smaller amount if you don’t do as well, but you’re not really getting hit with huge penalties across all of these programs, except with PQRS,” he says. “But if you look two, three, four years out, you’re going to start to see more of the downside, and that’s where it’s going to get very interesting in analyzing the financial risk of not making moves into population health.” Moving into population health requires organizations to reexamine how they deliver care, a difficult but necessary process. Dichter says nearly all medical contracting is shifting to a paradigm focused on quality and value. As a result, providers must demonstrate they’re working in that direction, a strategy that will pay off in the long run. “The organizations that I have worked with over the past several years who have been the most successful in taking on risk have decided to change how they practice medicine,” Dichter says. “One of the organizations that I worked with about a year ago was working with a managed care company through an ACO [accountable care organization] agreement. They identified a number of patients who had a fall risk, and they went to these patients’ homes and installed ramps. No one was reimbursing them for this. This was 100% out of their pocket. And the reason they did it was because they realized that the cost of installing the ramps was significantly less than the costs they would incur for hospital admissions and treatment of broken hips.” Interventions as simple as administering flu shots to at-risk patients and treating diabetic patients whose A1c levels are out of range can benefit both patients and providers. Dichter, who says uncontrolled symptoms account for some of the highest health care costs, believes connecting with at-risk patients is a significant opportunity to save lives and money. Cultural Awareness Data sharing plays a pivotal role in population health efforts. Although some government regulations mandate sharing and parts of the country have high levels of data exchange, not everyone is on board. While large multisite organizations regularly exchange data with other providers, small organizations in competitive markets may be reluctant to share patient information that they view as proprietary. Dichter says in some cases corporate philosophies work against effective health data sharing, adding that decision makers must recognize that health care delivery has changed in the past 20 years. In today’s environment, patients are routinely referred to out-of-network providers. Patient collaboration also is becoming more integral to health care delivery. Rather than simply dictating prescriptions and dispensing medical advice, clinicians must now build a relationship that will help patients make informed decisions about their own care. To effectively improve population health, a culture change is needed, says Ellen Donahue-Dalton, chief marketing officer of Medecision, a provider of population health management tools. “The health care system tends to look at things from an inside-out standpoint,” she says. “The idea of switching the dynamic and thinking about consumers as an informed and engaged part of the process is a little foreign to a lot of care delivery organizations. Typically, they think about patients or consumers coming to them when they are ill and need care. [The providers] fix the problem, the patients go on their way, and everybody’s better.” Donahue-Dalton says consumers, who tend to think this way as well, must be educated to change their longstanding perceptions. One goal of population health is to encourage patients to participate in their care, but getting their attention can be a challenge. Donahue-Dalton says it won’t be a quick or easy process to convince people to change their behaviors and take steps to remain healthy, but it can be done. One leverage point will be financial: As consumers assume more financial accountability for their care, they will ask more questions and demand more transparency. They also may begin to think more about how their health choices have consequences, she says. Perhaps the biggest leverage point, however, is social pressure. Preacute reminders, such as alerting diabetic patients when their A1c levels are out of range, and postacute reminders about medication compliance and follow-up visits can be effective, Donahue-Dalton says. However, including family members or close friends in the process can enhance their effectiveness. Donahue-Dalton says community networks, or care circles, comprised of people selected by the patient can help keep at-risk populations on track with their health regimens. “I think we have the technology tools in place. The key is putting them together in an arrangement where the right incentives and information are shared. That is where [population health] will become interesting,” she says. “The first generation is just smartphone app registration, secure messaging, and being able to view a patient’s clinical timeline via smartphone. It’s all current technology. The challenge is to develop an ecosystem that allows this information to be used effectively.” The ecosystem must encompass patients and providers across the entire continuum of care. If population health initiatives are to have a significant impact on public health, getting the right information at the right time to the right people throughout the chain of care will be essential, Nash says. With patients being tracked in hospitals, wellness centers, rehab centers, ambulatory surgical centers, nursing homes, and at home, it will be a drastic change in how consumers view health care delivery. “There will be a greater interest and concern in the broad spectrum of where care is delivered, most especially outside the four walls of the hospital,” Nash says. “Population health is going to be a real challenge in coordinating the information across diverse care settings because population health, among other things, is going to emphasize the move from inpatient to outpatient, from acute care to prevention and wellness, and from volume to value. People will be pushed out of their comfort zones into aspects of the delivery system where they really have not played a prominent role.” — David Yeager is a freelance writer and editor in southeastern Pennsylvania. SURVEY: POPULATION HEALTH EFFORTS LAGGING IN IT ADOPTION As the emphasis on the change in delivery of care escalates from volume- to value-based care, population health management initiatives are becoming more prevalent across the health care industry. However, many organizations are addressing their initial population health needs without a population health vendor-provided IT solution. A recent survey, available at himss.org/News/NewsDetail.aspx?ItemNumber=46055, offers insight from nearly 200 health care executives (C-suite, administrators, directors, and vice presidents) on their population health initiatives, and their current and future approach to population health IT solutions and consultants. “While roughly 67% of surveyed organizations claim to have population health programs in place,” says HIMSS Analytics Director of Research Brendan FitzGerald, “only one-quarter of those currently utilize a vendor-provided solution to address their population health needs.” Other highlights of the survey include the following: • Roughly 11% of study respondents with initiatives in place currently use a consultant for their population health strategy. • More than one-half of study respondents without current population health initiatives in place plan to employ initiatives in the future. • More than one-third of organizations with plans to employ population health initiatives in the future plan to use a consultant or would consider it. — SOURCE: HIMSS.ORG

Words Matter: Best Practices for Dictating in an EMR Setting

As HIT matures, dictation and transcription models continue to evolve. It’s a situation being closely monitored by health care organizations concerned about the fallout from potential productivity losses and physician outcry over clunky EMR documentation workflows. To combat these fears, many facilities are considering models that incorporate dictation back into the fold.

“I think one of the primary reasons organizations make the switch is that they have provider dissatisfaction,” says Billy Allred, director of IT and business development at Pennsylvania-based Opti-Script. “They have providers upset that they are spending three and four hours a day entering notes.”

While physician satisfaction is one part of the equation, productivity looms just as large, says KB Anand, CEO of Pennsylvania-based Acusis, noting that losses in that regard impact the bottom line and catch the eye of the C-suite. “Having an option to dictate helps physicians maintain productivity, especially in specialties like cardiology where extensive documentation is required, but at the same time, every minute of the cardiologist’s [time] is money,” he says. “So the question is where to spend that time.

A cost-benefit analysis will easily advocate the physician doing a quick and easy dictation and moving on to the next patient rather than spending additional time point-and-clicking or struggling with the structured templates in an EMR.”

Anand also points out that specialties such as psychiatry require greater narrative than can be provided by structured documentation fields. This need for greater detail can’t be met in a controlled context, he adds.

Opti-Script President Sharon Allred, CMT, AHDI-F, says that health care organizations are challenged in their efforts to balance physician productivity with legislative and fiscal obligations. She recommends adopting best practices to incorporate dictation models or face the consequences of documentation errors and omissions that can impact patient safety and revenue.

Industry professionals agree that regardless of how the final document is produced following dictation, there must be quality assurance (QA) in place to ensure accuracy and completeness for patient care and coding. For instance, Bryan Medical Center in Lincoln, Nebraska, has instituted a QA program for their providers and trained medical transcriptionists (MTs) to work as trainers and analysts.

“QA is essential,” explains Leigh Anne Frame, HIM manager at Bryan Medical Center, “QA of the report itself, but also checking that [clinicians] used the right template, inserted it into the right location in the EMR, identified the right patient, etc. In the beginning, we did 100% QA, and then we tapered off.”

As health care organizations consider the best models for dictating into an EMR, industry professionals offer guidance on sound practices and potential pitfalls to keep watch for.

Do Get Clinician Buy-In
Frame emphasizes the importance of gaining clinician buy-in when implementing a model for dictating into an EMR, whether an organization employs traditional dictation and transcription, front-end speech recognition, or a hybrid model. For Bryan Medical Center, identifying the right approach proved challenging.

“I’m still trying to find that happy medium,” Frame acknowledges, noting that clinicians initially agreed on a “once-and-done” solution for their dictated reports. “Even though we provided very good turnaround time with traditional dictation, by the time we transcribed it and [clinicians] went into the EMR and edited it or signed it, the turnaround was obviously extended by quite a bit. Even though it might take them longer up front, they felt it would save time in the long run, and that turned out to be true as we monitored it.”

According to Sharon Allred, a key ingredient to clinician buy-in is allowing providers to choose their workflow. Accomplishing this goal requires flexibility in how dictation is offered as well as the provision of a validation function behind the dictation model for QA.

Sherry Doggett, an industry veteran and former president of the Association for Healthcare Documentation Integrity, agrees. “Offering clinicians full or partial dictations within the EMR encounter allows choice, and if they have a difficult case, dictating either full or partial dictations allows for more robust documentation,” she says. “Partial narratives are ideal because the clinician can use the templates and drop-down boxes within the EMR but [also] add the patient’s story, which is so important.”

Don’t Make Assumptions About Quality
While speech recognition technology has come a long way in the last decade, few in the industry would suggest that it’s foolproof. Sharon Allred says that trying to accomplish dictation goals without a validation piece in place is a sure way to create an opportunity for both minor and critical errors. “Patient safety is potentially compromised in that regard,” she says. “Just leaving out a ‘not’ or ‘no’ is critical in a lot of situations.”

Billy Allred notes that providers often overestimate the quality of their dictation, believing that minus a few commas and periods, it’s probably in pretty good shape. In his experience, the reality is much different. In fact, a recent client analysis revealed that 11% of provider work contained a critical error. “Just because a provider thinks they are doing a good job or just because an office staff person peruses the document … doesn’t mean data are accurate and complete to the level needed for coding,” he says.

For example, one recurring issue that Doggett has noticed is that physicians are not pulling up the correct encounter within the EMR. “It is easy via traditional dictation [into a digital system] to correct if caught at the point of transcription,” she points out. “Unfortunately, if the clinician chooses the wrong encounter, it is much more complicated to place within the correct encounter. This can occur with full dictations or partial narratives.”

Do Consider the Technological Framework
EMRs are here to stay. But instead of resisting any new workflows the technology may introduce, Anand recommends learning how to dictate properly to produce the best documentation. This starts with being sensitive to the capabilities and limitations of the EMR being used.

Frame suggests that a high-quality speech microphone is essential to good voice recognition. “If you have the clinician’s buy-in, they will look at the words appearing on the computer screen, but they don’t always pay attention to content,” she says. “So, the [voice] recognition needs to be as good as it possibly can be.”

Equally important is the functionality of the front-end speech recognition software, Frame says, pointing to user-friendly yet robust offerings that make it easy to create and use shortcuts, expanders, and text inserts. “Just as important as the front-end speech recognition software is the computer itself,” she adds. “We found conflicts with some applications that are Citrix based. The speed and amount of available memory on the PC is very important, as is the network connection. If it isn’t consistently fast or if the network connection is slow or often lost, even for a split second, clinicians will be frustrated, and it won’t be long before they’ll quit using it altogether.”

Once the infrastructure is in place and limitations are identified, Anand suggests that dictation provide as many details as possible that can be integrated back into the EMR to ensure quality documentation for analytics is present and ICD-10 requirements for specificity are met. “If the details are not provided, then every other patient case looks the same, and the reporting becomes cookie-cutter and stereotyped, which is against providing individual and personalized care for each patient,” he says.

While specifics are important, Anand cautions that providers stay away from dictating details that cannot be captured into the target EMR. While transcription may pick up those details, if there is no field for them in the EMR, they cannot be subjected to further use or coded and billed. “EMRs in general accept data in discrete blocks once it is transcribed rather than as a narrative,” he notes. “So, the dictation should result in a transcript that can produce these discrete elements, and the physician should adjust his habits that support it.”

Anand says it’s worthwhile for health care organizations to investigate technology advancements such as “narradata,” which produce discrete data from the unstructured narrative reports and can be electronically or manually synched back to an EMR for meaningful use and core measure reporting.

Don’t Skimp on Education and Training
Frame underscores the importance of training clinicians on proper dictation methods, suggesting flexible options that are catered to different learning styles. “One size fits all does not work,” she says, adding that training should be held onsite by the vendors as part of a workflow model. “Webinar training does not work well when training front-end speech recognition with clinicians. It’s also best to have two trainers: the vendor to do the [speech recognition] training and someone from within the facility to do EMR training.”

Sharon Allred points out that as traditional MTs transition to new roles as editors and health care documentation specialists, they must be educated on general coding issues and critical documentation elements. “It’s not that they have to be a coder, but they have to understand the role the encounter’s documentation plays in reimbursement and patient care,” she says. “There is a lot of critical thinking required.”

For example, in ICD-10, fractures now must be documented on various levels. Without this specificity, providers will find it difficult to obtain the proper reimbursement.

Anand recommends that MTs be trained on best practices for the dictation itself. “Once the dictation is converted into a transcript, it contains two types of data: data that have a place inside a specific data capture element inside an EMR and data points that are orphans which go into the EMR as free text,” he explains, pointing out that while it is easier for an MT to convert any part of the documentation as free text, they should avoid this path. “Free text should be entered only when the specific EMR does not have an option to capture a dictated data point. Omitting it makes the report incomplete, and the MT’s knowledge about the target EMR’s capability becomes vital in these situations.”

Industry Complexities
While there are advantages to dictating in an EMR, there are limitations. For example, vendor nuances can make interfaces with transcription and QA more difficult. “Often the client is left to make the best of the situation,” Sharon Allred says. “It requires that our IT staff be much more competent and knowledgeable about interfacing.

Anand points out that lack of standardization among EMR vendors makes life more difficult for physicians. “For example, if you look at the interfaces that each EMR system provides to enter a progress note, they look different,” he explains. “Vendors implement EMR features differently, and a physician moving from one EMR system to another has to struggle to interact with the new one in the new format if they want to switch systems.”

Sharon Allred notes that the variances between EMRs require third-party services to take more of a partnership approach with clients to ensure the most effective documentation and output quality. For this reason, Opti-Script conducts a complete analysis of workflows to determine the best approach, taking into consideration physician preferences and documentation practices to ensure the organization can work collaboratively to elevate documentation.

“For us, it’s harder to get decision makers to stop and think that there has to be a better way,” she notes. “They have listened to EMR vendors say, ‘This is so easy’ [in relation to EMR dictation]. They are placing unrealistic expectations on their providers, and they think technology can do it all.”

Anand says allowing some form of dictation in an EMR environment makes the most sense. “Health care provider organizations that went into the hybrid approach—allowing physicians to use an EMR to enter data directly while giving them an option to dictate—are better off than those who went the hard way of shutting the door of dictation altogether,” he says. “The learning curve of the physicians while adopting EMRs has been significantly lower for those who had an option to dictate when needed. For those physicians whose time is super critical, the return on investment is always better using a transcription service than forcing them to spend additional time in documentation.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.

Engage Patients to Boost Preventive Care

When it comes to following care instructions, it’s generally agreed upon that a lot of patients don’t do a particularly good job of adhering to their physicians’ orders. In fact, according to “A Fragile Nation in Poor Health,” only one in 20 health care professionals gives their patients an “A” grade for sticking to directions about becoming healthier. This is frustrating for providers who simply want to see patients get healthy and stay that way.

Many physicians wonder how they can not only make patients understand that they are obstructing their own care but also engage and transform them into becoming active participants in the process. The secret to overcoming these hurdles may lie with technology-enabled patient outreach.

Health care consumers can be a frustrating lot. They can walk out of the physician’s office and immediately forget the instructions they just received from the health care team. Yet, chances are good that if they are prompted by their Fitbit to take some extra steps, they will get moving.

This seems to indicate that patients often need encouraging reminders to help motivate them to take the actions necessary to improve their health. This is why physicians and other health care providers must devise engagement strategies that patients won’t ignore. More specifically, between-visit text messages, e-mails, and automated voicemail communications can offer support and help keep patients on a path to good health.

Health in Hand
Pew Research data indicate that 92% of adults in the United States own a cell phone, with nearly seven out of every 10 of those being a smartphone. People are constantly connected to their phones and other devices that allow them to receive and respond to messages. And not only are patients accessible but they also are receptive to receiving digital communications regarding their health. A West Corporation survey found that 51% of patients who received a voicemail, text, or e-mail from a health care provider felt more valued. In addition, 35% said digital communication improved their opinion of their provider, and 34% felt more certain about returning to that provider for care.

Many providers are unaware they already have technology in place that allows them to create and send automated engagement communications. Existing appointment reminder technology can be optimized and used to send automated texts, e-mails, and voicemail messages that promote preventive services, share information, and solicit patient feedback. For those already using appointment reminders, all it takes to actually make patient engagement a routine part of care is maximizing technology that is currently being used.

Engagement in Action
Health care organizations can use their appointment reminder technology to send engagement communications that encourage participation in preventive care. In fact, providers across the United States are finding that sending automated messages that prompt patients to take action (eg, schedule preventive screenings and immunizations) produces results.

For example, Ochsner Health System called patients with recent orders for a colonoscopy and left an automated message notifying them that they were due for the screening. Ochsner’s message—which urged patients to schedule the test—worked. Outreach efforts attracted patients who admitted they would not have taken steps on their own to set up an appointment. In fact, so many screenings were scheduled that in just two months, Ochsner generated nearly $685,000 in additional revenue from colonoscopies.

Scottsdale Medical Imaging had a similar experience when promoting preventive services. The organization sent automated voicemails to patients who were past due for a mammogram. The voicemails resulted in 1,200 mammograms being booked during the course of a year.

At both Ochsner and Scottsdale Medical Imaging, engagement communications prompted patients to act and sparked an increase in preventive care.

Overcoming Hurdles
Consider the reasons patients don’t seek preventive services on their own. One of the biggest challenges of trying to expand routine services to healthy patients is that health screenings and services are not top of mind for people when they are not sick. Technology-enabled engagement messages are the perfect solution to this problem because they can bring awareness to preventive care, help patients understand why and how to keep up with routine checkups, ease concerns about the cost of preventive screenings, and more.

One question providers sometime have when it comes to creating engagement communication campaigns is whether they have the resources to support their efforts. Because communications can be automated, minimal investment is all that’s required to launch such efforts. Plus, depending on the messages sent and the services promoted, providers can bring in additional revenue that more than pays for the time and resources needed to develop communications campaigns. That’s because technology-enabled outreach can help land new patients, book a full calendar of appointments, reduce patient no-shows, secure payment for services, and minimize bad debt write-offs.

Lasting Benefits
In response to a West Corporation survey, 35% of patients (who admitted they don’t closely follow prescribed treatment plans from their health care providers) said they would be more likely to follow directions if they received reminders from their physicians via e-mail, voicemail, or text. Providers have the tools in place that they need in order to change that. Health care teams that utilize appointment reminder technology to deliver communications promoting preventive care can drive greater participation in routine care and help improve patient outcomes.

— Allison Hart is an advocate for utilizing technology-enabled communications to engage and activate patients beyond the clinical setting who leads thought leadership efforts for West Corporation’s TeleVox Solutions.

EMRs – A Solution Inside a Problem

The roots of the problem-oriented medical record may stem from a bygone era, but its concept still rings true today.

The problem-oriented medical record (POMR) is a comprehensive approach to recording and accessing patient medical data. First developed by Lawrence Weed, MD, in the 1960s, the POMR gathers information from all members of the patient’s care team in order to determine a diagnosis and create a treatment plan. The POMR typically includes the patient’s history, a list of symptoms, test results, a treatment plan to deal with each issue, progress notes, and a discharge summary, including any follow-up steps that must be taken.

Matt Douglass, cofounder and senior vice president of customer experience at EHR vendor Practice Fusion, offers an example of how a POMR works.

“You can think of a POMR as a different view, a different type of filter by which a physician orders the patient’s problems,” he says. “For example, if a patient is suffering from wheezing and coughing, the physician asks questions and, through this investigation, discovers the patient has additional complications—say pet dander—that have spurred asthma. From a POMR standpoint, the patient has allergy-induced asthma, and a treatment plan would then be developed.”

POMRs are especially beneficial for documenting chronic illnesses, which may require multiple treatment methods that must be adjusted over time. The tool also helps cases in which patients with complex medical issues see more than one physician. Such documentation is particularly important when the treatments for multiple illnesses interact. In addition, POMRs help patients become better educated about their own health issues and how they are being handled.

The Value of the POMR
In today’s EMR environment, the POMR is likened to the subjective/objective/assessment/plan, or SOAP note, a form of documentation that allows clinicians to include notes in the patient record. In the POMR, the SOAP note not only encompasses the patient’s history, test results, and other pertinent health information but also the physician’s observations, a list of issues prioritized in order of importance, and notes on why the problems are organized in a particular way. Furthermore, it’s divided into three distinct components for diagnostic, therapeutic, and patient-education plans.

According to Susan Schulte, a medical solutions specialist, certified trainer, and HIT compliance officer at the Center for Computer Resources, the POMR was widely used from its inception through the 1980s. “The POMR was a functional way of documentation,” she says. “Through to the ’80s, a doctor could follow the format similar to that of the current SOAP note and be able to articulate his findings and recommendations by being focused on a problem—not just on the symptoms and facts around the problem.”

However, Douglass believes that few of today’s EMRs use Weed’s concept of the POMR. “The term POMR has gone in and out of vogue over the years,” he says. “When Dr. Weed first created the POMR, he did so to educate his medical students. At that time, it was a new way of looking at medical records; it is fairly hierarchical. Essentially, it’s diagnosing as you go.”

Still, Douglass says components of Weed’s vision have found their way into today’s EMR software. “The POMR is really the foundation of the SOAP note, which is the standard flow that physicians use. In many cases, the SOAP note forms the core of current medical recordkeeping,” he says.

Physician documentation, especially when it comes to problem lists, in the EMR world has been largely shaped by meaningful use requirements, says Sandy Routhier, RHIA, CCS, CDIP, owner of HIMpoint. “The way [problem lists] have been incorporated into the EMR by vendors or how hospitals use them; it hasn’t been going well,” she notes. “In fact, when I see a problem list in an inpatient record, I tend to ignore it because the entries are inaccurate and not well-maintained.”

Currently, few EMRs rely solely on Weed’s concept, in large part because the POMR represents a different way of thinking and requires more time spent with patients during office visits, hospital stays, and aftercare. Additionally, it requires cognitive time to think through how problems may come together into a single list and how to maintain its accuracy. “[The POMR] is not how physicians have been trained, and it would take them more time,” Douglass says. “Physicians tend to look at one thing at a time. However, physicians that have been working in the field for a while can work well with the POMR. Unfortunately, moving from how physicians are currently trained to taking the comprehensive approach of the POMR requires time and training.”

The arrival of ICD-10 has further complicated matters, Routhier notes. “Imagine an orthopedic surgeon attempting to add a fracture diagnosis to a problem list and being presented with more than 17,000 options. He or she is just going to pick one that looks close and move on,” she says. “The problem list is then being autopopulated into a physician’s templated reports such as daily progress notes and discharge summaries and it’s junking up the record. A good narrative description of a diagnosis by the physician is preferred and let the coding professional assign the code.”

Henry C. Chueh, MD, codirector of the Massachusetts General Hospital Laboratory of Computer Science, notes that when Weed created the POMR, it was easier to establish a story over time because physicians often saw the same patients on a consistent basis. While EMRs are beginning to evolve into problem-oriented systems, physicians must manage patient problems separately by using the SOAP notes in the current software. “At Mass General, we have a conceptual model, and the problem is central,” Chueh says. “That problem list becomes part of the same problem list for patient office visits, too. Physicians can drill down and see all the notes related to that problem, and can move around the record easily.”

Schulte believes most physicians are not trained to take a hierarchical approach to addressing health issues. That, plus workflow issues and the structures of most EMRs, prevents widespread use of the POMR. A complicated reimbursement system doesn’t help matters either, she notes. “In the past, whatever the problem was, the doctors just wanted to take care of it. Now, in order to get paid, the doctor has to pull other things from the EMR,” Schulte says. “I don’t want to take away from a really good practitioner’s caregiving. As much as they want to be excellent caregivers, doctors can’t do that and stay in business if they are not also focused on how they will be paid.”

Adds Douglass, “The POMR gives a more holistic way of looking at the issue and requires a great deal of data entry. We’re not quite there yet as an industry. It requires entering family history, all allergies, medications, test results, and other information, and it requires more data than medical records are collecting at this point. As vitals and more information get plugged into EMRs, those are helping us get to that point. Physicians will begin to see that we are dealing with a holistic problem, which is a more comprehensive view.”

Places for a POMR
Some settings are more conducive to POMR use than others. For example, the POMR is less likely to be used in an outpatient setting in which patients are seen for only a few minutes and turnaround is fairly rapid. In hospital and home care settings, however, physicians are more focused on organizing patient issues into primary and secondary hierarchies. Therefore, the POMR is becoming more prevalent in both hospitals and home environments where clinicians can take more time evaluating and working with patients.

“We are also seeing the POMR in academic settings where teaching physicians are willing to experiment and try different things,” Douglass says. “When Dr. Weed created the idea, it was when he was teaching other physicians.”

Larger health systems also are looking into using the POMR as they seek ways to innovate and help their physicians improve care. “The thinking is more widespread than perhaps the acronym currently is,” Douglass says.

Chueh believes a POMR is beneficial in any setting that treats the same patient for the same disease over time. “You may have multiple doctors in any particular facility. And if a patient is being seen by more than one doctor, to have all those records woven together is very useful. So wherever there is a continuum of care, the POMR is a useful document,” he notes.

John Squire, president and chief operating officer of Amazing Charts, the developer of a new POMR called InLight EHR, adds, “If you have a problem that develops over time and gets worse or better, you can track that with the POMR. For instance, a patient may have back pain that comes and goes over a number of years. Physicians can track that development over time. If the pain is intermittent and then becomes visible as something, such as arthritis, then the doctor can track that long-term problem, make an accurate diagnosis, and develop an effective treatment plan.”

Pros and Cons
Most experts agree that documenting in a traditional POMR is a time-intensive process that requires significant interaction with patients and extensive tracking of health information. Other drawbacks also stem from time-related factors, Schulte notes. “You don’t have the time to comprehensively document with all the descriptors that you need,” she explains. “That prohibits doctors from using this type of system. It’s not terribly efficient, and physicians have to be efficient in order to survive.”

For this reason, Schulte says POMRs have fallen out of favor. “Even if you went back five to seven years ago, the use was much more extensive. I don’t know of any doctors who work with it, and I consult with more than 75 doctors on a regular basis,” she says.

While POMRs excel at organizing information within medical record documents, Routhier says the industry is not taking advantage. “Is it being used effectively and to the best potential? No. Physicians don’t receive a lot of formal training related to medical record documentation methods and formats,” she says.

Routhier commends physician’s notes in which the assessment and plan section is problem-focused. However, such an approach can create the following challenges:

• Failure to link conditions to underlying causes for accurate combination code assignments. “Congestive heart failure, for example, may be an entry in the problem-based record with the underlying cause (ie, hypertension, valvular disease, ischemic cardiomyopathy) possibly entered as a separate problem and the conditions are not linked,” she says.

• Listing a body system, sign, or symptom without associating a diagnosis. “For example, a physician may list the problem as renal rather than the associated diagnosis such as chronic kidney disease or acute kidney injury,” Routhier says.

• Listing a differential diagnosis in a format that appears to be a definitive diagnosis: “You sometimes see a physician document UTI [urinary tract infection] without using uncertain terms such as ‘possible’ or ‘likely,’ then she or he stops treatment after negative cultures, but never says the UTI was ruled out,” Routhier says. “That becomes problematic when there is uncertainty whether a condition was ruled in, ruled out, or uncertain at the time of discharge.”

For purposes of POMR use, the sooner a diagnosis can be made, the better, Chueh says. “To the degree that you want to have the kind of record a POMR provides, you have to make decisions early for what kind of problem you want to diagnose,” he says. “Patients will come into the hospital and present with certain symptoms, but you don’t always know what the diagnosis is yet. You have to find the problem early in order to create a comprehensive record in this way.”

However, if this hurdle can be overcome, the comprehensiveness of POMR documentation can lead to rich data analytics possibilities provided the caregiver has the time, conduit, and tools available.

“Additionally,” Chueh adds, “many conditions patients have are chronic. If you’re able to organize your information in a problem-oriented fashion, then the POMR becomes an easier process over time because the data are organized in that way for each patient and offer a fuller picture of each patient’s health care needs.”

The POMR and Coding
While a POMR can be beneficial in some clinical settings, the type of documentation it generates may be too simplistic for billing purposes. To code correctly, Douglass says coding billers would have to interpret the specifics of the POMR. “In the ‘rolled up’ version of the POMR, its components are organized into a hierarchical list; therefore, the coder would need to access the more extensive list,” he says. “They would have to be given an expanded view. Coding billers who are really in tune with the doctor, though, should have no problem with the POMR.”

Schulte notes that experienced coders should have no trouble working with a POMR. “But for newer coders, especially with ICD-10 being rolled out, they have to go through notes and make sure all the boxes are checked,” she explains. “The POMR is more time-intensive, and coders can’t afford to do that in this day and age. It’s something that they need to read and look at carefully for problems. Even if they break it down into a SOAP note, they have to go through that and look for key points. The rigidity of the requirements means we don’t have that luxury anymore.”

Chueh believes that the problem-oriented EMR software at Mass General helps coders and clinicians. “Our software package makes it easy for a clinician to document a patient’s problem and map it to the correct ICD-10 code(s), which makes it easier for coders to validate the information,” he says. “It helps them avoid taking that second step of looking up codes. When they are looking at higher levels of reimbursement, coders can identify what are new and old problems, and differentiate whether issues are chronic or acute.”

Chueh clarifies that coders do not rely entirely on the software, noting that the technology helps the clinician create documentation that can minimize the extra time needed to review each record to validate the information. Specifically, the software is not proposing or generating any codes itself; rather it makes it easier for a clinician to document with problems that are mapped to ICD-10 codes. The problem-oriented notes clearly organize the information needed to assess the medical-decision characteristics of the visit, he adds.

Routhier cautions coders not to rely solely on technology. “There is still a need for coding professionals to interpret the medical record entries then apply coding guidelines, index and tabular instructions, AHA Coding Clinic advice, etc, while keeping in mind clinical validation and opportunities to further clarify documentation (in the form of a query if needed) prior to making the final code assignments,” she says.

Connecting With the EMR
“In the ideal world, every caregiver wants solely to care for patients and see them get well, but right now, I see it flipped,” Schulte says. “A doctor has to break down everything: ‘This patient has COPD, and this is how we will address it.’ In the current environment, doctors have to prove a person is sick to justify care and get paid. Many more steps and things must be addressed and recorded. That said, without question, use of the POMR affects each specialty differently, and integrating the EMR with the POMR, beyond the SOAP note, will likely happen in ways that benefit each specialty.

“It’s just a matter of time,” she continues. “Over the years, I have known doctors who have been paid by barter, but they can’t afford to do that anymore. I also know doctors who maintain practices in underserved areas and don’t want to retire because no practices will start up in those areas after they stop working. It would be too expensive for new physicians to fill their shoes, so there simply won’t be access to medical care in those places once they leave. Experiencing those scenarios has helped me realize that there is still goodness in medicine despite all of the hurdles physicians must move past. And, as we continue expanding the features of the EMR in this digital age, we will likely find our way back to documenting cases in ways that look more like what Dr. Weed originally created.”

— Susan Chapman is a freelance writer based in Los Angeles.