Crossing the Quality Chasm: Who’s Engineering the Building of the Bridge?

By Chris DeFlitch, MD, FACEP, CMIO

Let’s take a hard look at the Institute of Medicine (IOM) goals to cross the quality chasm: safe, effective, patient-centered, timely, efficient, and equitable (SEPTEE). All laudable goals, but HOW do we get there? Spend more money?  Trillions of dollars in annual health care expenditures are sure not solving the problem.   How about squeezing the physicians or hospital payments and only paying for “quality”? Maybe that will work.  Buy more and better IT system?   Maybe everything electronic, we get transaction level detail… that way people can be tracked.   Oops, that was not very politically correct.   I mean, “Provide tools to support best practice.”  While cost containment and HIT are a part of the issue/solution, we have to focus on the quality of the delivery system.

As CMIO, I live the joy and pain of Heathcare IT.  Seems to me that, across the industry, especially related to “meaningful use”, “experts” are pushing healthcare IT.  Frankly, patients, providers, and administrators who think that HIT in and of itself is a solution, are wrong.   Electronic medical records (EMR) are not the panacea, they are just another tool to build the bridge.

Here’s where the gap occurs.  There are tons of dollars provided as “incentives” under meaningful use to push us in that direction. Unfortunately, much of the health care industry is so far behind in understanding the depth, breath, and complexity of the care process that overlaying an EMR in a “rapid implementation” without consideration for the processes of care might lead to less than optimal experiences for the PEOPLE involved, the patients and the providers.  I often hear, “Can’t we just get an alert that pops up and tells folks what to do?” I’ve come to describing this phenomena as “sprinkling a little IT dust” to magically make things better. Guess what? It doesn’t work that way. Health care at its core is a person caring for another person.

We must understand and address the processes of care system-wide, based on people interacting with people, using technology…….. engineer the crossing of that chasm.  There are growing and devleoping quality, HIT, and people management components that can be used as tools to creating system that works. Bottom line…technology is an enabler, and even a facilitator, but in and of itself, not a solution. It’s the process of care that needs to be re-engineered.

Let’s take a very practical example of documentation and the dichotomy between “efficient” and “effective.” EMR tools permit pulling information from other parts of a patient’s chart into the document.  Systems also facilitate pre-population of a note with important data elements into a patient chart from previous visits. Seems like a pretty efficient principle, and it does make creating a document faster… but it is that more effective?   The result is a document, pre-populated with a bunch of accurate data, qualitatively and quantitatively accurate, but the experience and “story” of the patient, the person who is seeking care — and the person who is taking care of that patient — is lost. The effective communication of care, from person to person for another person is lost in the bits and bytes of our electronic monster. Ultimately we must figure out how technology facilitates better care rather than directing it.

Please don’t misinterpret: I think that EMR technology has facilitated the advancement of many health care processes and will continue to do so, if implemented with patients and providers in mind. We created, designed, and built an emergency department that has no front-end waiting room and a completely new methodology of care delivery in emergency medicine based upon data reviewed from EMRs. We’ve dedicated resources and created a center by which we look to discover how process of care can be improved, with academia and industry (with the right funding) via our Center for Integrated Healthcare Delivery Systems.

Ultimately, the healthcare delivery system is broken and we have an obligation to fix it. But, without core system engineering, and process understanding, HIT only makes bad processes faster.

—Christopher DeFlitch, MD, FACEP serves as CMIO of Penn State Hershey, and vice chair of emergency medicine. He has led the institutional conversion to the EMR; and led inpatient, OR, ICU, outpatient, patient portals and ED through process redesign. To support the expansion of this work throughout all components of health care, he’s co-founded the Penn State University, Center for Integrated Healthcare Delivery Systems (CIHDS). Follow him on Twitter: @cdeflitch