Finally, an emerging key principle for effective chronic disease management is the shift from physicians managing individual patients during office visits to nurse coordinators managing disease populations outside of visits, assisted by care algorithms and work-management software programs. Telephone follow-up is a powerful tool in the hands of nurse coordinators, optimal care can be assured across the inpatient–outpatient interface, and community resources can be mobilized for home care.
This population management approach will allow rheumatology practice teams to say, “We have 1,500 RA patients, 80% of them have controlled disease, and we are focused on maintaining these and improving the rest.”
21st-Century Information Technology
Different rheumatology practices are at different stages of implementing EHRs. While early adopters have already suffered through the learning curve for a decade, experiencing added time burdens, lower patient throughput, and “death by 1,000 clicks” common to switching to EHRs, others are only beginning to recognize what they are in for. Some practice tasks are facilitated by an EHR: lab review, e-prescribing, phone messaging, and information sharing among users. The benefits for performing other work are not so obvious to providers—diagnostic ordering, for one. Implementing today’s EHRs will not always improve care and efficiency, even if they are used as effectively as possible; new generations of IT will be needed.
Today’s EHRs are transactional databases with information stored in files, like paper medical records. Different bits of information have fixed relationships to others. In contrast, analytic databases store pieces of data in individual cells that can be more flexibly sorted and related to others. This leaves today’s EHRs weaker than analytic databases for analyzing patients’ clinical data and for organizing work within provider teams and disease populations. Analytic disease registry and work management software products are beginning to emerge for these critical functionalities that may interact with, but are separate from, EHRs. Some are even able to manage patients with comorbidities, the most challenging cases for improving outcomes and reducing resource use and costs. IT “meaningful use” will require both EHRs and disease-registry/work-management software programs. Building these within health systems is time and money intensive; using web-based and turnkey programs will be more practical for many practices and systems.
The potential for EHRs to improve patient care is also compromised in many health systems by the multiple brands being installed in different practices, Health Insurance Portability and Accountability Act regulations preventing information sharing among providers about shared patients, the focus on billing documentation rather than optimizing care, and the multiple functional options that compromise standardization. EHRs are often less efficient for consulting specialists whose patients come from referring physicians with different IT systems. Learning to use one EHR is daunting; learning one for the office and one for the hospital is worse.