Marshfield Clinic's EHR and chronic disease management

The Marshfield Clinic's use of their EHR was featured in the "Evidence Gap" of the New York Time's Business Section on December 26th. The Marshfield EHR is a "vibrant tool that reminds and advises doctors. It can hold information on a patient’s visits, treatments and conditions, going back years, even decades. It can be summoned with a mouse click, not hidden in a file drawer in a remote location and thus useless in medical emergencies. ...Modern computerized systems have links to online information on best practices, treatment recommendations and harmful drug interactions. The potential benefits include fewer unnecessary tests, reduced medical errors and better care so patients are less likely to require costly treatment in hospitals" writes the Times' reporter, Steve Lohr.

Screenshots and examples of use include:

1. A pediatrician using a tablet computer to quickly manage a visit for an asthma exacerbation (reviewing meds, ordering a CXR by circling with a pen device on the tablet and then reviewing the image on the tablet with the patient and mom),
2. Improvement in prevention and complication management of their diabetic population, and
3. Use of MA's and nurses to "work the iList" of patients who are overdue for blood pressure checks, vaccinations, etc., and bring them in for these preventative services.

The Clinic's use of the EHR tools to manage patients with chronic disease and its participation in a Medicare demonstration project which "selected the clinic and nine other large doctor groups and arranged to pay them for the quality of care they deliver. Last year, on the basis of how well diabetes patients had fared, by various measures, Marshfield was one of only two groups that did well enough to earn bonus payments." (I add the the University of Michigan Health system, which is my employer, was the other group that earned a bonus payment, and thus was deemed to have satisfied the requirments for PQRI. Our system doesn't seem as sophisticated as the Marshfield system, but our family practitioners use a scaled down EHR and reminder system, a portion of which is available as a stand-alone commercial product.)

Lohr points out that "the organizations tend to be big — ranging from providers with thousands of physicians like Kaiser Permanente and the Department of Veterans Affairs to ones with hundreds like Marshfield and Geisinger Health Systems in central Pennsylvania. They are typically responsible for most or all aspects of a patient’s care. They are often insurers, as well."

In addition to their size -- which allows the Marshfield Clinic to amortize the development and implementation cost over many practices -- two other keys to their success include the involvement of physicians in product development, and leadership at a senior level. The process of development of the EHR, and its continuous modification and improvement, involved the users of the system. In-depth involvment of the users is a particular feature of "homebrew" systems, and is difficult (and expensive) to replicate in large, commercially developed systems in my view. (I also note that there was no mention of oncology tools in the article.)

Marshfield also has devoted, senior-level physician leaders involved, including a medical director of clinical informatics, a medical director of quality improvement and care management, and the physician chief executive. Buy-in of senior leadership is critical to success of these EHR projects, as many have noted.

Organized physician groups and their ability to improve quality and cut costs

Alain Enthoven riffs on large multi-specialty group practices in an Op-Ed piece in last weekend's NYT. He is a Stanford professor of management and long time thinker on health care topics.

He has in mind the Marshfields, Kaisers, and VAs, which incorporate hospitals and insurance companies, and in which the "doctors work together to improve quality and to keep costs low." He goes on to note " that most American doctors are weak on prevention and chronic disease management. But they will not improve until they are given economic incentives to buy the equipment and hire the personnel they need to actually deliver these services."

Because most current physicians "are autonomous, not members of teams. They do not systematically share information with one another. They are unable and unwilling to be held accountable for the quality and cost of the care they deliver....Some American medical practices do emphasize economy. They are very large, multispecialty group practices in which doctors work together to improve quality and keep costs low. Their doctors share values and cultures of teamwork. They keep comprehensive electronic medical records, they share information, and they emphasize disease prevention and chronic disease management as a matter of course."

I think is analysis of most of our practices is spot on. As we grow our EHRs and remodel our workflow and tasks, we need to keep in mind the potential for data mining of our EHRs to improve best practices, to abandon ineffective interventions or those interventions which add no value, and to share data with one another and with our referring physicians and consultants. Additionally, we need to resolve the tension between oncology-specific EHRs (which may share patient data easily with other care-givers) and the one-size-fits all EHR being adopted by many hospitals and health care systems (for which oncology care is often an afterthought).

ASCO's potential to organize oncologists for quality and to deliver value

So, I think that it's a race. Will the large organizations -- hospital-based, university-based, multispecialty physician driven or oncologist driven -- use their EHR's and their resulting data wharehouses to dominate the market? Or will the "small" physician practices --the one to ten oncologist practice -- be able to organize themselves into virtual groups to deliver quality care on the same level?

Further, will we oncologists continue delivering our current level of diagnostic, treatment, and follow-up services, and demonstrate our quality and value, at a cost that society is willing to pay, as well as to expand our services to include financial counseling, preventative care, genetic counseling and survivor management?

I think it's possible. We can't wait for a government organized global solution to do the best for the patients whom we see every day. ASCO's EHR workgroup, which has laid out some excellent requirements for a safe and valuable EHR here and here, is a great start. ASCO's QOPI program, which thus far is volunteer driven and a labor of love, and in which practices caring for over 13,000 cancer patients participated, is also a great organizational move. ASCO's ongoing efforts to promote the research and development arm of oncology, through our promotion of translational and clinical research, is also critical. Guideline development, refinement and adoption is also a critically important effort of the Society.

ASCO's continuing advocacy for our patients and for oncologists and for our teams, are critical to delivering the best outcomes and continuing to improve survival, regardless of where our patients live or the practice model of their treating oncologist.