Tuesday, August 16, 2011

Modernization of Patient Care Management

The current United States healthcare system is in transition from an era driven by paper records, human paper-handling and telephone calls, to an of era of electronic health records, people connected through mobile devices and the Internet, with moment-to-moment collaboration, communication and coordination.
In this article, I discuss a potential patient care system that exploits current computing and communications technology to transform healthcare delivery to a more integrated, responsive and efficient system.  I begin with related observations on the current state of the healthcare system, followed by a list of principles for an improved system, and finally I discuss modernization based on current information technology.  I conclude with references to current standards work that enables this transformation.

The Current System

Below, I focus on four fundamental problems with the current healthcare system: (1) care management is fragmented and inefficient, and (2) there is a failure of competition, (3) adoption of new medical technology is too slow, and (4) automation is preserving legacy systems.
1.      Fragmentation.  Healthcare providers tend to operate in silos, delivering their special capabilities.  An individual’s healthcare records are scattered among different providers.  The patient becomes the inefficient courier of records and medical information.  There is minimal coordination of care among specialists.  Tests are often duplicated, and risks of interactions may be overlooked.  Providers do not have incentives to share records with other providers.
2.      Competition.  Providers do not compete for patients based on service quality and price. Under capitation-based, managed care, patients choose providers from the payer’s network.  Providers are paid a fee for each covered patient, so they have incentives to minimize services and avoid patients with high service needs.  Under fee-for-service, providers are paid for performing services; more services generate higher income.  They receive the negotiated rates regardless of the quality of care.  Patients only see their deductibles, co-pays and denials of coverage, and they are not informed purchasers of healthcare services.  Unlike other markets, cost and quality have minimal impact on a patient’s treatment decisions or choice of provider.
3.      Technology transfer.  Transfer of new medical technology, including new services and procedures, from research to practice is hampered by many factors including FDA approval, denial of insurance coverage, provider business risk, resistance to change, and malpractice lawsuits.  The market does not reward rapid adoption of advanced medical technology. 
4.      Legacy systems.  Information technology has had a significant impact on medical testing and diagnosis, but, for the most part, it has not changed the way care is managed.  Automation of legacy systems solidifies conventional methods and may make the overall healthcare system more difficult to change.  While paper has been converted to electronic data and data is entered and viewed using electronic devices.  Patient records are more vulnerable to electronic intrusion, and the management of patient care remains unnecessarily fragmented, unresponsive, inconsistent and inefficient.
These problems require transformation of the healthcare system.  In this article I focus on one aspect—transformation of the way patient care is managed.

Key principles

Of course there are many principles for good healthcare.  The following principles are particularly relevant to patient care management. 

Market-Driven Improvements

For effective competition, provider pricing and quality improvements should be driven by market demand as expressed by patients.  Treatment decisions by patients should reflect consideration of cost as well as performance of providers.  Providers should be free to charge what they believe their services are worth, and consumers should be able to select a more expensive service that exceeds their coverage if they believe the value of the service to them merits the additional cost.  Demand from patients who are willing to accept the increased cost and potential risks of new technology should drive adoption of new technology as a competitive necessity.

Informed Consumers

Patients (consumers) should make informed decisions in their selection of care providers and treatment options.  Physicians are responsible for educating a patient about their treatment needs and options.  Costs and outcomes of procedures and medical conditions, including availability of advanced technology, should be published using standard categories and designations so they can be compared across providers.  A consumer should be able to consider providers and treatment alternatives along with the net out-of-pocket cost reflecting their insurance coverage.

Physician Leadership

Coordination of care requires medical expertise.  A primary care physician and his/her team should have responsibility for the overall health of a patient and coordination of care.  Primary care physicians must know when a patient should be referred to a specialist, must have an incentive to refer rather than treat, and must track and coordinate care.


The patient, the primary care physician and specialists, along with their respective teams, must collaborate to provide appropriate planning and treatment for the whole person.  Collaborative planning and follow-up should be life-long (at a level of intrusion determined by the patient) addressing not only acute and chronic care, but also health monitoring and preventive care.

Development of Best Practices

Generally, physicians develop their own best practices.  Professional groups must collaborate to define, share and continuously improve industry best practices.  This includes adoption of advanced technology and improvements to performance measures.  Acceptance of best practices should be supported by empirical data on performance and outcomes from controlled trials.  Performance measures and associated reimbursements must provide appropriate incentives for utilization and improvement of best practices.

Risk Management

Outcomes must be analyzed and rules must be formulated to define and manage risks.  Risk should be assessed based on patient circumstances and alternative technologies, while considering regulations, medication interactions, contraindications and conditions requiring immediate attention.  Risk data should be available for professionals and patients considering treatment options.

Medical Records

Patients and personnel of their authorized medical teams, as appropriate to their individual roles, must have timely access to the patient’s current medical records from all sources.  Even though individual providers go out of business, lifetime patient records must be available to support diagnosis and treatment as well as research. Reliable security methods must ensure privacy of patient medical records and enable the patient to restrict access by professionals based on need to know.  Providers must accept that patient records belong to the patient, and records must be available to support diagnosis and treatment by other providers.

You Get What You Pay For

Quality care requires extra effort to educate patients, collaborate with treatment teams, develop best practices and share medical records.  These efforts must be paid for or they won’t happen.

Application of Information Technology

Information technology is changing the way the world works.  The cost of computers, communications and data storage have become negligible.  Individuals can be always connected through mobile devices.   Computers can help improve timeliness, consistency, validation, guidance and retrieval of information, and they can alert professionals to emergent conditions and the availability of relevant information.  Computers can also relieve professionals of tedious, repetitive tasks, ensuring that they are performed in a timely and accurate manner. 
My previous article describes a vision of “The Knowledge Worker Cockpit.”  Healthcare professionals are knowledge workers.  That technology is a basis for the following characteristics of a future care management system.

Engagement of Services

Consistent data on provider rates and outcome statistics as well as availability of new technology should be publicly accessible, particularly in support of patient selection of a provider.  Web services should support comparison of out-of-pocket costs of different providers based on the coverage schedule of a patient’s payer.  As a result, providers will compete for patient business.  The patient should be able to proceed to schedule a doctor’s appointment and obtain preliminary tests based on symptoms, medical records and potentially a teleconference with a medical professional (see telehealth, below). 


Collaboration is an important and often overlooked element of good patient care management.  A primary care physician should collaborate with specialists, and each physician should collaborate with his or her team.  Some collaborations may engage international experts in teleconferences.  Information technology can support collaboration through communication of messages as well as scheduling and support of meetings and teleconferencing.  This may be obvious in a hospital setting, but it should continue in community care and through transitions between community and hospital care.


Telehealth supports some aspects of healthcare remotely, using electronic devices and communications.  This includes devices for monitoring vital signs and other symptoms as well as support for collaboration between patient and professionals.  Patients, particularly in remote areas, may resolve some health problems without the necessity of travelling to an office, clinic or hospital.  For others with chronic conditions, it provides monitoring of symptoms that might otherwise require hospitalization.  The data collected by electronic sensors or patient inputs can be sent directly to a care management system for monitoring and initiation of alerts to professionals if important changes occur in the condition of the patient.

Treatment Planning and Coordination

The care management system will be highly interactive and support collaboration on treatment planning and decision-making.  Pre-defined planning elements will include guidance and constraints, links to defined services (e.g., lab tests) and frequently occurring patterns of activities applicable to particular situations or medical conditions, including best practices.  Individuals doing treatment planning may capture frequently used tasks and patterns of activities in their personal libraries to expedite their planning efforts.  Treatment plans can be developed and changed as the patient’s circumstances evolve.

Timely Response

Automated plan management will provide personal schedules along with follow-up actions on events such as alerts on over-due activities, reports of relevant information, and completion of pre-requisite activities. Critical changes in the condition of a patient can trigger alerts or corrective action to ensure that appropriate action is taken in a timely fashion.  Appropriate professionals or their alternates can be notified immediately regarding key events via mobile devices.

Electronic Health Record

There has been much attention to the development of electronic health records (EHR).  The primary care physician, the specialists and their teams must all have access to a consistent, shared EHR (not necessarily stored in one location).  A patient HER should provide access to all current medical information and should be retained, under patient control, for a lifetime medical history. The system will apply standards for the form of various types of records or transformation of records from different sources to a consistent form.  It also will support timely communication of updates.  Records must be accessible to authorized personnel only to the extent authorized by the patient.  Authorization and withdrawal of authorization must extend to all sites where a patient’s records may be accessed or replicated.

Audit Trail

The care management system will generate an electronic audit trail of activities performed, events that occurred, decisions made, and the associated circumstances as defined by the EHR.  The system should provide the ability to reconstruct a case snapshot that reflects the state of the case at a particular point in time as the context for events, activities and decisions.  An audit trail will also track individual accesses to medical records for privacy assurance.  Records on services to individual patients will provide the basis for reimbursement for services, including services delivered through remote monitoring, teleconferences or other means that do not require a physical meeting of the physician and patient.   


Computer-based analysis of treatment histories will provide insights on treatments, health trends, causes of medical conditions, and best practices.  The care management system will provide data on actual practices and outcomes to support identification and improvement of best practices and analysis of risks.  Applications will support analysis of outcomes, costs and timeliness of procedures as well as identification of factors related to variances in treatment, outcomes and total costs of treatment for specific medical conditions. 


Interactive guidance can provide support for use of best practices and can both encourage and support consideration of new technology.  Guidance can be provided in terms of task requirements, planning and decision-making alternatives, risk and cost factors and contingency plans for emergent conditions.   Guidance may be triggered by the initiation of certain activities, or it may be determined by automated reasoning triggered by events and based on the patient’s EHR.  A more sophisticated system may “learn” case circumstances when certain activities or patterns are often initiated and suggest them to physicians. The system may also inform the physician of current trends or epidemics that may be relevant to the patient’s condition.


Constraints can be specified for the planning or initiation of tasks, task completion criteria, authorizations as well as actions that may be affected by regulations, interactions or contraindications.  Constraints can help prevent mistakes or oversights and enforce policies and procedures.


The automation of patient care management is typically envisioned within a hospital setting where solutions can be implemented and governed by a single administration.  However, patients don’t spend their lives in a hospital; for most people a hospital stay is a brief episode in their lives.  Advances in information technology will support automation that integrates hospital care, community care, remote care, continued health monitoring and preventive measures.
The facilities discussed above are based on technology described in my previous blog post on “The Knowledge Worker Cockpit.”  The goal is to provide access to “power tools” for knowledge workers, such as doctors, nurses, medical technicians and others, including patients, who must participate in health care and make decisions about services based on their personal insights, experience and expertise in order to do the job right.
Development of standards is a key challenge.  The healthcare system consists of many independent providers and payers with scattered patient records and diverse computer systems.  The activities of multiple providers must be integrated and coordinated through shared supporting technology, and the records (or interfaces to them) must be consistent for sharing and electronic processing through compliance with an Electronic Healthcare Record (EHR) standard.
The Object Management Group (OMG) is developing a specification for case management modeling (Case Management Model and Notation) that supports the modeling of specific types of cases (including patient care management).  A case-type model will provide case record specifications and planning elements that make it easy and flexible  to plan and manage individual patient care in collaboration with others, to streamline care management and to improve the quality and timeliness of outcomes.  
The OMG Healthcare task force is working on additional standards in cooperation with the HL7 standards organization.  Public recognition of the value of these standards, along with demand for their implementation, is a key factor in transforming the US healthcare system.

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