Implementing health information technology to improve the process of health care delivery: a case study
Review by Mark Binstock MPH MD
SUMMARY This paper describes how two information technology systems relate at the Marshfield Clinic. The first system is an electronic medical record (EMR). This is an in-house developed EMR for capturing clinical data that was begun in the 1960s. The EMR does include a snapshot or “Dashboard” functions as well as reminder system for overdue services. The second system is a chronic disease management system (CDMS). Marshfield purchased this proprietary system, InformaCare from Pfizer Health Solutions Inc. The purpose of the CDMSs is to manage patients with chronic conditions usually done with a non face to face encounter by a chronic care team. This includes functions for risk stratification, care guidelines and care management protocols. In the case of the Marshfield clinic, this team consists of 11 RN care managers, 2 nurse supervisors, 1 data manager, 1 data analyst and 2 health service coordinators. They have managed 1000 patients with diabetes.
They conducted a provider satisfaction survey on the addition of care management including CDMSs . The response rate was 32% with an N of 46. 67% “strongly agreed or agreed” it was helpful. Additionally providers thought this care management improved the quality of care (50%), patient’s satisfaction (33%), saving provider time (22%) and saving staff time (26%). About 15% of the article text deals with one clinical vignette.
In their conclusion they state “…how the use of 2 distinct health information technology systems can be adapted by large, multispecialty health care system to potentially improve the overall efficiency and quality of care.” They also mention that a limitation is that the EMR and CDMS were not electronically linked
COMMENTARY This article is for the most part a description two health information technology systems at Marshfield Clinic: the electronic medical record (EMR) and chronic disease management system (CDMS). “Results” are limited to a provider satisfaction survey, reported in one table. No data is presented on quality measures, safety, timeliness or efficiencies.
This article deals with a problem now facing many who have implemented an EHR, namely that although an EMR may and should be effective for managing individual patients; EHRs now available do not lend themselves to population care management. Most providers using an HER in the course of time limited office encounters do not have time to provide comprehensive chronic disease management. Hence the advent of care management and disease management which were basically an outgrowth of disease registries like pap tracking, cancer registries, transplant registries. As the number of patients in these tracking systems grew, there became a need for information management tools, databases. The distinguishing feature of CDMSs is that they imbed ARTICLE electronically management guidelines and protocols.
From the description in the article, it does not appear that the Marshfield EMR includes computerized provider order entry (CPOE) or a Drug- Drug Interaction module. Although care management programs and CDMSs were conceived to manage patients with multiple chronic medical problems like diabetes, hypertension, hyperlipidemia, congestive heart failure, especially for patients who had multiple chronic health problems, at Marshfield the care management team is managing only the diabetes. What is striking from the article is how rich their care management staffing is (17 full time equivalents) caring for only 1000 patients with only one chronic disease (diabetes). It hard to see how this program could be considered economically viable especially after software purchase costs are considered. What is even more surprising is with the large clinical management staff devoted to the care management of these relatively few patients that the program did not register a more convincing impact on provider satisfaction.
What is needed is fully integrated disease management modules within an EMR.
