EMR and Utilization Management – They Are Linked
Collection, analysis, centralization and access make the EMR an essential component in optimizing utilization
By Jay I. Pomerantz, MD – Executive Medical Director for Health Integrated
It seems intuitively obvious that in order to drive optimum utilization, you need to have systems for data collection, analysis, dissemination and access. We’ve been talking about the vital role of utilization management (UM) in advancing healthcare reform. It would seem that to drive fundamental changes to our healthcare system, the first goal would be to make sure the system is running optimally efficient. Simply put, preventive care would be the standard discipline, effective triage and the subsequent doling out of the right care for the right patient at the right time (and precisely no more), would be routine. These practices would not only streamline the system, but save resources and time. Ah, the Utopian society.
So, then we are awaken to our current realities.
We are still living in a piecemeal clinical world. For the most part, less than 20% of healthcare facilities (physician office practices and hospitals) maintain a synchronized electronic medical records (EMR) system[1]. This is a meager showing since data collection and access to formatted information is a key to driving better outcomes. Enter the EMR. Not only should this be a staple for any physician practice group, but on a broader level, this aggregated information can be used to optimize best practice and drive utilization management to meet the overriding goals of increasing the appropriateness of patient care while optimizing resources which would save both time and money.
From our current polling, better than 91% of respondent health plans currently have a UM system. As well, all respondents agree that an EMR is an essential component in planning and executing UM. Interestingly though, less than one-third of the respondents have an ‘evidence-based’ medicine program. This meta-analysis would seem to be the basis for effective UM. We might just be wrestling with semantics though. That aside, I am a staunch believer in physicians and their abilities to utilize their expertise and available resources to diagnose, treat and follow a patient to better health. As well, they also have my support to be preventive and drive patients to optimal health when given the time and the resources. As physicians, we must take the lead or we will be lead by the dictate of others – not that it would be bad, but I believe that the best healthcare is administered when we let doctors be doctors.
That said, this autonomy which leads to better outcomes is not possible without clinical information – both on a patient-by-patient basis and in the aggregate so trends and best practice can be established. An effective EMR is at the core of this process. As I’m sure you remember, within the American Recovery and Reinvestment Act (ARRA) stimulus program, there was an unprecedented $36B allocated to implementation of EMRs within physician’s office practices and hospitals[2]. The financial incentives offered to these facilities were on a sliding scale with more reimbursement being offered the earlier an EMR is adopted and implemented. Interestingly and concerning however, is that there are close to 300 or so EMR vendors (depending on how they are counted and when the count is made). My worry is that a “tower of babble” is being constructed between facilities. The ‘meaningful use’ (MU) definition, which dictates how reimbursement can be made – meeting certain criteria, has been incrementally detailed over the last several years, the latest definition being rolled out just last month. Prior to that, funding could be received under ARRA for EMRs based on the scale I referred to earlier. Don’t get me wrong, there is no question as to their benefits to a physician practice for such activities as keeping track of patients, synchronizing charting activities, centralization of information, and creating a secure and accessible portal internally. As well, for the patient, an effective EMR allows a patient remote access to their medical records, scheduling, prescription refill orders, insurance claim filing, clinical information access and availability, auto-reminders and appointment scheduling, to name a few.
Should a patient bounce between facilities, there likely will not be the synchronized data access and flow needed to optimize either patient care or resource allocation, unless you happen to reside in one of the few locations that have begun to develop regional health information exchanges (RHIO’s). As well, the potential benefits of a broader-based UM system, built upon a broad clinical database will not be aggregated or accessible until most of the EMRs are ‘certified’. Some of the larger vendors are certified under the current MU guidelines. The goal of HHS is to gain a 75% adoption rate for EMRs by 2017, and if not, the plan would decrease the Medicare/Medicaid reimbursement rate to any non-compliant facility. Although noble, this represents a formidable goal given the current adoption rates and decreasing incentive reimbursements.
EMRs are a key component to driving utilization management and subsequent reforms to improve care and reduce the associated costs.
What do you think?
Thanks for reading. I would also welcome your thoughts on topics that would interest you. Please contact me directly at healthexecforum@healthintegrated.com or you can comment directly in the blog.
Best Regards,
Jay I. Pomerantz, MD
[1] “Electronic Health Records in Ambulatory Care-A National Survey of Physicians,” June 18, 2008, New England Journal of Medicine.
[2] PriceWaterhouseCoopers, Health Research Institute, “Rock and a Hard Place”, April 2009
