tech time

EHR, Value and Clinical Evidence

How EHR will open the door to a value-based-medicine model.

SCOT MORRIS, O.D., F.A.A.O.

In case you missed it: On February 17, President Obama signed into law the American Recovery and Reinvestment Tax Act of 2009. Included in this massive recovery package: $20 billion earmarked for health information technology. Proponents of the law say that implementation of this technology will save our country billions of dollars per year in unnecessary healthcare expenditures and loss of life.

In addition, on January 16th, the U.S. Department of Health and Human Services reported that it postponed the implementation date of ICD-10s to October 1st, 2013. This was an obvious move, since to accurately track outcomes, we need to be able to identify all the various forms of disease. The current ICD-9 medical classification covers about 17,000 conditions. The ICD-10s will cover 155,000. Finally, we will have a correct code for some of the diseases that we see every day.

A model based on value

How will electronic health records (EHR) fit into the complex puzzle of value-driven medicine, or, at least, how will it affect our profession? Though I have no crystal ball, a few basic tenets seem self-evident — at least ethically and morally.

Our healthcare system will ideally move toward a value-based medicine model. Value-based medicine incorporates both evidence-based medicine and pay-for-performance characteristics. Below, I discuss the evidence-based medicine portion of the equation.

Show the evidence

In summary, evidence-based medicine is showing that what we do for our patients actually works. For example, if I were to ask a room of O.D.s how many recommend hot compresses for their patients who have meibomian gland dysfunction (MGD), everyone's hands would go up. Yet, not a single study (evidence) shows that hot compresses have clinical significance in the treatment of MGD.

In all facets of medicine, evidence-based medicine could save this country hundreds of billions of dollars on tests and medicine that have little to no clinical evidence to support their use. In our current system, it takes millions of dollars to bring a single drug to market. That drug has no more than a few clinically proven indications. However, once it comes to market, doctors try it in all kinds of off-label ways. Many of these ways are never proved in a clinical study and, if they are, it is in the "perfect" patient population. Funny thing is, I can't remember the last time I saw the perfect patient.

Understanding "real" success

With evidence-based medicine, we can actually track the success of drugs and devices in a much broader, "real" patient population — the whole country. Now, this requires that we not only transfer codes and fees to our EHR system, but all clinical data associated with each patient. It also requires a centralized healthcare database, which is currently available, just not utilized, yet. We have computers that can process a pentabyte of information per second. We have the technology to "crunch" any numbers. We just need to feed them real data. ICD-10s as well as documentation, such as Physician Quality Reporting Initiative (PQRI) standards, will provide that data.

Next month, we'll continue our discussion regarding value-based medicine and look at pay-for-performance. OM