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Meaningful Use: A Good Earth or Scorched Earth Path

December 6, 2010
by Joe Bormel
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One hospital's good earth path to MU

This past week, I had the pleasure and honor to spend four hours on medical attending rounds at a major integrated health system in the Northeast I’ll call IHS. It’s top rated in several national performance initiatives with well recognized brands and, like all other great systems, publishes very respectable performance in quality, cost and access metrics.

Also, like the majority of hospitals in 2010, IHS hasn’t yet rolled out the most challenging clinical pieces of Stage One MU – inpatient CPOE and well-constructed problem lists. To its credit, IHS is a strong Level 3 in the HIMSS Analytics EMRAM, and has clearly had many tangible clinical successes leading toward Level 7. As you read on, you’ll find that IHS is a pretty healthy place for the organizational improvements that underpin MU.

I witnessed a number of great clinical practices that led me to the conclusion I would prefer having my family and friends receive care at IHS when compared to the actual care I’ve experienced at other hospitals. For example:

1. IHS has established a practice of bringing patients’ families in on rounds. Family members not only know when rounds will be, if they’re not able to attend in person, the clinician will call a designated family member from the patient’s bedside on speaker phone. Given the near ubiquity of cell phones, it wasn’t a big surprise to learn that patient and family satisfaction is high.

2. Also present throughout rounds, or at least very nearby the patient room and closely participating, are the patient’s assigned nurse and/or nurse manager, a pharmacist, and others determined to be central to care. They include other clinicians, social workers, case managers, translators and clinical administrators. This practice has been evolving at IHS and elsewhere over the decades since my residency training in the form of family rounds in ICUs and executive patient safety walk rounds. Both of which pretty much never happened as a routine when I was in training.

3. There are shared information artifacts in printed form being used personally and between IHS staff to enhance communication and efficiency. Everyone had them. I saw evidence of both harmonies and disharmonies; great stuff to feed improvement initiatives, and drive adoption and buy-in.

My reaction? What a wonderful setting to introduce enhanced problem lists and CPOE disciplines. What a great setting to further push communications and collaboration disciplines outside of the four-walls and cell phones to electronic, timely discharge documentation for not only patients and their families, but also their referring physicians and remote care providers.

Several patients were not only not in the IHS catchment, but often several states away. The “send and receive patient summaries as interoperable documents” require the kind of cultural and work flow developments that IHS is clearly piloting today. The patients getting care from longer distances will receive some of the greatest benefits from improved post-discharge care coordination.

If my dad or mom were admitted to your hospital today, would I be informed of when I was invited in for daily rounds? Would you be able to offer me phone or video conferencing at the bedside with the clinician on rounds? Would the discharge documentation look like the impersonal, Xerox paper notes with circled, vague information that I was recently given after my mom received a VVI pacemaker placement? Much to my horror, it also included discharge instructions for an implantable defibrillator, which she didn’t need or receive.

That was the best this hospital could offer; and it has implemented CPOE. Personally, I’d rather my mom had received her care where communication is correct and clear as a first priority. CPOE, although an essential safety enhancement, is beside the point when it’s not communicating accurate information to care providers and patients.

Satisficing (From Wikipedia)

Satisficing, a "handy blended word combining satisfy with suffice", is a decision-making strategy that attempts to meet criteria for adequacy, rather than to identify an optimal solution. A satisficing strategy may often be (near) optimal if the costs of the decision-making process itself, such as the cost of obtaining complete information, are considered in the outcome calculus. ...

After visiting IHS, I am encouraged. While there, I witnessed a high standard of satisficing care, rather than a decade long roadmap for some “planned” optimized care. I was thrilled to see clinicians, despite the absence of fancy Stage 7 infrastructure, doing the critical scaffolding today, and exceeding common, non-HCIT based personal and professional standards. The quality of care at IHS comes first, and these people are delivering excellent care. This is the “good earth” path to MU.

What’s your practical clinical environment like in terms of hosting the Meaningful Use requirements?

Joe Bormel, M.D., MPH
CMO & VP, QuadraMed

Benjamin Disraeli: It is easier to be critical than correct

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