Stanley Feld M.D.,FACP,MACE
If you ask a number of physicians to define quality medical care, most will come up with a definition close to the Institute of Medicine’s definition.
"The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."
Systems of medical care are necessary to reproduce the results of clinical trials for chronic disease. How does one develop a system of care to decrease the complications of chronic diseases? One must divided the elements of quality medical care into separate modules. The result should be the improvement of medical care outcomes.
Quality of Medical Care should be defined specifically to include all the elements of quality care. Continuous quality improvement means improving the processes used in fulfilling each element of quality care.
The elements of quality care are as follows:
1.Recognize patients at risk for diseases
2.Do appropriate evaluation
3.Make the appropriate diagnosis
4.Start the appropriate treatment
5.Schedule the appropriate follow-up
6.Stimulate the appropriate compliance/adherence to treatment
Goal is to decrease complication rate, morbidity, mortality and cost of care
Three of the six element of quality medical care can be automated by the ideal EHR. Three of the elements require physician judgment and patient participation.
1. Recognizing The Patient At Risk
The following are screening procedures to detect disease early so preventative measures can be taken:
a. Cholesterol and HBA1C measurements every 5 years if normal
b. Fecal occult blood yearly after age 50
c. Flexible sigmoidoscopy/Colonoscopy every 3-5 years after age 50
d. Clinical breast exam yearly
e. Mammogram yearly after age 50
f. Pap smear every 1-3 years
g. Clinical testiscular examination once a year
h. Digital rectal exam yearly after age 50
i. PSA yearly after age 50
j. Influenza yearly
k. Pneumococcal once after 65
l. Tetanus/Diphtheria every 10 years
m. Hepatitis A once
n. Hepatitis B once
o. Osteoporosis indications for bone density
All using steroids > 65 > 40 with low trauma fracture > age 45 with risk factors
One can easily see that the EHR can cue the physician to screening tests and timing vaccinations automatically. Automating this process of quality would increase the detection of disease early. Appropriate timing of vaccines can prevent disease. The patient could also receive advanced notice of screening procedures due through the PHR (Personal Health Record) module of the Ideal EHR.
2. Appropriate Evaluation
The appropriate evaluation is at the physician’s decision using his medical judgment. The physician’s clinical judgment is the most important element in the diagnostic decision. Options could be provided by the EHR. However, it remains the physician’s judgment. He could elect a less invasive test for some illnesses depending on the patient and the patient’s circumstances.
3. Make The Appropriate Diagnosis
The physician has to interpret the test with the patients history in mind. He has to read the studies with an expert if he has an incomplete report. There are many subtle changes in laboratory studies that indicate disease and can not be picked up by a computer. Guidelines should be provided. An example of what I am talking about is the early detection of a low bone density secondary to both osteoporosis and a vitamin D deficiency. The calcium will be normal to low or high, the phosphate low normal, the alkaline phosphatase high normal. This is a clue to osteomalacia secondary to vitamin D deficiency. Further testing is necessary to make a diagnosis that would otherwise be missed and blunt the effect of the appropriate therapy.
4. Starting The Appropriate Treatment
Starting the appropriate treatment is the physician’s decision. The evidence based medicine could be connected to the EHR. The clinical outcome of his decision could be available for his own education by the EHR.
5. Scheduling The Appropriate Follow-up
Scheduling the appropriate follow-up can be done at the point of physician service through the EHR. The physician can be guided by evidence based medicine guidelines instantly. If it is important to see the patient sooner the physician can override the guidelines and justify the visit.
6. Compliance/Adherence To Appropriate Therapy
Compliance/adherence to appropriate therapy is essential for improved outcomes. The compliance/adherence rates reported in the literature are awful. The range is 10% to 50%. There is too little emphasis on the patient’s responsibility to adhere to medical therapy. However, patients live with their disease 24 hours a day and should have the burden of being responsible to adhering to therapeutic regimes. The defect is that the patients often do not understand the significance of the therapy. Patient education is essential. Patients have to become the Professor of their disease. The physician has to be the educator himself, or with the use of physician extenders. Education by built in information to the PHR (Personal Health Record) can help. Interactive patient interactive sessions can also help. If the patient does not take the medication we can not hope for improved outcomes. The physician can track the patient adherence through electronic communication with the pharmacy to determine compliance through refill frequency. The EHR can automate this conduit of adherence.
Quality medical care is not only about evaluating patients at risk. It is only the first step in quality medical care. The other five steps are just as important. I tell physicians it is not about how many bone densities you do, or how often you measure the HBA1C for diabetes mellitus, it is about preventing osteoporotic fractures, and decreasing the complication of diabetes mellitus.
Practicing the process of quality medical care should decrease the complication of chronic disease. The translation of evidence based medicine to clinical practice is a continual process of quality improvement. The ideal EHR could help greatly in achieving this goal.