• Healthcare quality can be effectively measured using EHR data
• Quality of diabetes care can be improved through the use of EHRs
• This can be done on a regional basis, beyond the scope of one hospital or health system
• EHRs are superior to paper records in improving quality care, demonstrating the Meaningful Use Concept
• This is true over different insurance types.

More background on the initiative, Better Health Greater Cleveland is available Brian Ahier’s blog and on the BHGC website. It is supported by a grant from the Robert Wood Johnson Foundation.

Conclusion: Why shouldn’t this be done more broadly, even nationally. Perhaps through Meaningful Use it will permeate more broadly.

Dean Ornish

Today I heard Dean Ornish speak and came aware more convinced that prevention of disease through lifestyle changes can have a major impact on the future of health. Particularly, the potential impact on the epidemic of diabetes in the US is huge. We all have heard about how more and more of our population is becoming obese and the subsequent increase in diabetes and metabolic syndrome. If lifestyle changes can prevent even 10 or 20 percent of the progression to these serious conditions, imaging the impact on quality of life, work productivity and healthcare costs. This Thursday, Cleveland Clinic and Slate magazine will co-host a summit on Childhood Obesity.

Not only that, but he notes research on his website, Preventive Medicine Research Institute, that there is a potential impact on cancer and telomerase activity.

On a related note, a new interview with Daniel Kraft is posted on the TEDxMaastricht website. He talks about how mobile apps are just beginning to become available and used for lifestyle change but predicts that access to medical records and other patient empowerment tools will become common.

How can we get the word out, shift from unhealthy foods and lifestyles and move toward a healthier country?

My conclusion is that the use of clinical decision support within EMRs can impact quality on a national level but that early implementation of EMRs may take time to demonstrate this impact.

In a video on Huffington Post Video last month, the interview at the Cleveland Clinic about the successful EMR still questions whether this success can occur elsewhere. Yes, the implementation was expensive and expensive to maintain but the benefits over paper are quantifiable in terms of quality of care and improved outcomes. Maybe the lessons of successful EMRs have paved the way for others.

Finally, Dr. Cosgrove, CEO at the Cleveland Clinic is interviewed by Fox Business News at the Davos World Economic Forum. He again repeats his contention about the need to address obesity and health care costs. Again, a model or approach to care and costs which others can emulate.

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The authors address concerns about “cookbook medicine” but rightly describe medicine as a cottage industry: “Services are often highly variable, performance is largely unmeasured, care is customized to individual patients, and standardized processes are regarded skeptically. Autonomy is hardwired into the system, because most physicians practice in small groups with limited oversight or coordination.”

How do we move to post-industrial care or even better, 21st century, technology-enabled, patient-focused care. Does that mean that small practices should join large practices, academic medical centers? The authors don’t propose that solution, but do propose following clinical practice guidelines which are flexible enough to manage individual differences in presentation. If medicine is trending toward broad implementation of clinical practice guidelines and a stronger focus on outcomes (value-based medicine), technology-centered particularly around the electronic medical record and a focus on efficiency, can small practices survive? Are will moving toward industry consolidation much like what has been experienced in banking?

The cottage industry of medicine with fee-for-service as a funding model, continues to drive up cost without adding value. While I am no economist, I believe medicine is changing and models of practice which focus on efficiency, technology and patient experience are taking the lead.

One final quote from the article: the authors characterize this cottage industry as chaos – “Chaos confounds constructive action, whereas wise standardization is a foundation for effective variation, efficiency, reliability, and rapid innovation.” Let’s hope that wise standardization through guidelines can promote the kind of rapid innovation needed to transform healthcare and that policy and funding decisions follow this direction.

• fee for service model is toxic to improving health outcomes
• Competition must be based on results.
• Competition should center on medical conditions over the full cycle of care.
• Results information to support value-based competition must be widely available. (aka, disease registries)
• increasing value actual reduces cost.

He also reemphasizes some basic principles that are strongly backed by evidence – high volume regional medical centers typically have better outcomes that low volume centers. But he acknowledged that consumers must realize that local care may not be the best care for especially for complex conditions.  Do you want to get your total knee replacement at a hospital which does one a week or 1400 per year? Not that volume is everything but consumers need to have the data available to make wise choices, outcomes data in particular.

He admitted some disappointment in the current health care reform because it does not change the incentives toward value-based competition. See How Reform Went Wrong.

• access to insurance including removing exclusions for preexisting illness
• consumer protection
• healthcare IT including PHRs and Health 2.0 and meaningful use
• cost controls
• quality outcomes including comparative effectiveness
• how it helps business and the economy

Such a document should include no buzz words or government 3 or 4 letter abbreviations, such as, ARRA. Some of this is already on the HealthReform.gov website but the President should try to break this down more consistently.

Finally, keep the patient at the center of healthcare reform – see this Health Populi post on the challenges.

• Access (too many uninsured people)
• Value (too much spending for the health results delivered)
• Ignorance (at every level – who really pays for health, misaligned incentives, true costs, quality measures, transparency and more)

He focuses on value and notes that innovation is not occurring in health care “because of the inflexibility in the payment system and misaligned incentive.”  Particularly, innovation regarding the management of chronic disease which accounts for 70%  of medical cost.

There will certainly be alot of discussion on realigning incentives to pay for outcomes rather than volume in the upcoming healthcare reform debates. It is long overdue.