James McGauley, M.D.

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Editor’s note: This article is the 10th in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which literally produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative.

The term “medical home” was introduced by the American Academy of Pediatrics (AAP) in 1967 to describe a central source of a child’s pediatric records. It particularly emphasized the importance of centralized medical records for children with special healthcare needs. The concept was introduced to address the duplication and gaps in services that resulted from a lack of communication and coordination among the different practitioners who cared for special needs children.

To address these problems, the AAP advocated for three steps to spread the word about the importance of the medical home: “The first requirement is the teaching of all medical students that a medical home and a complete central record of a child’s medical care are the sine qua non of proper pediatric supervision. Second, the concept must spread from physicians to all agencies and people caring for children—schools, child guidance clinics, well-infant stations, surgical specialists, emergency departments and so forth. The third step is the indoctrination of parents.”

In 1977, the concept of a medical home as a central repository for medical records actually became a formal policy of the AAP. Its statement read: “Quality medical care is best provided when all of the child’s medical data are together in one place (a medical home) readily accessible to the responsible physician or physicians.”

Expansion of the Concept, but Elimination of the Core Principle

Since 1977, the concept of a medical home has evolved and expanded, but in the process, the original idea that a medical home is essentially a 

In 2006, the Patient-Centered Primary Care Collaborative, a multi-stakeholder advocacy organization, described a medical home as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety.

In 2007, a consensus statement on medical home principles was jointly endorsed by the American College of Physicians, the American Academy of Family Physicians, the American Osteopathic Association and AAP. It defined a medical home as a healthcare setting led by a personal primary care physician that facilitates partnerships between individual patients, their personal physicians, and when appropriate, the patient’s family members.

The 2010 Patient Protection and Affordable Care Act mentions medical homes in the context of new payment policies, Medicaid demonstrations and the creation of Accountable Care Organizations.  

Recent articles describe a medical home as a partnership between patient, family, primary provider, specialist and community support groups whose goals are to provide comprehensive care and minimize gaps in healthcare delivery. Other articles describe it in terms of a personal physician, a physician-directed medical practice, whole person orientation, integrated care across the lifespan, enhanced access to care and payment structures that reflect the value of care management.

The initial AAP definition of a medical home was focused and specific — a primary care physician plus a Coordinated Medical Record for every patient. It was remarkably prescient of the AAP to define a medical home in this way because 1967 was a time when all medical records were still on paper, making it virtually impossible to generate a single, comprehensive, coordinated lifetime record for any patient.

All of the subsequent descriptions of a medical home are laudable but vague. They essentially define what primary care physicians already do — coordinate care for their patients and communicate with other care providers and family members.

What’s missing in the recent descriptions is the specific requirement for the coordinated and comprehensive information that automatically ties all of these functions together. It’s unfortunate that this requirement is still missing at a time when it is actually technically and logistically possible to provide this information to the caring physicians.

The simplicity of what AAP recognized long ago was that the formula for providing the highest quality of medical care was simply to have all of a patient’s healthcare information readily available to the providing physician at the time of every healthcare encounter. They recognized that a Coordinated Medical Record was the necessary foundation of a true medical home.

None of us get all of our lifetime healthcare from a single physician. As we all move through space and time, a consistently available Coordinated Medical Record would allow all of our primary care givers to provide us with a top quality medical home without them needing to build the foundation of that home from scratch every time.

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A Coordinated Medical Record System Defines the Holy Grail of Healthcare IT

True Value-Based Healthcare Requires a Coordinated Medical Record System

A Coordinated Medical Record System Is 96% Outpatient Focused

Articles

A consistently available record would allow PCPs to provide patients with a top quality medical home.

A Coordinated Medical Record Is the Foundation of a True 'Medical Home'

Editor’s note: This article is the ninth in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative.

 that produces a single, comprehensive, privacy-protected, automatically-updated patient record that is continuously available to the patient and to all authorized caregivers essentially defines a “Holy Grail” type of IT system.

Single, comprehensive medical records are the ultimate patient-focused records. The continuous availability of those records to all caregivers means that everyone is working with the same patient information all the time, and that is the core principle that leads to a significant increase in the quality of healthcare. And, it is the documentable increase in the quality of care that ultimately determines the appropriate cost of care.

A Coordinated Medical Record system is modeled after the credit card industry, which has proven that it is both technically and logistically feasible to establish a customer-centric data management system that captures and organizes billions of random transactions every day.

Groups of bankers founded the companies that developed and deployed the credit card systems. Currently, there is no comparable entity in the healthcare industry, so one needs to be established. It needs to be a new corporation in the middle of the healthcare industry whose sole purpose is the neutral management of medical records.

, the founding members would be a handful of activist physicians and representatives of major national corporations. These potential founders are currently sitting on the boards of national physician and employer organizations that are looking for ways to improve the quality and decrease the cost of healthcare.

The employers can easily fund the start-up of this entity and can subsequently use their collective power as the ultimate source of most healthcare dollars. These individuals can redirect insurance premium and healthcare tax dollars to fund the ongoing functioning of this information system.

Physicians are the ones who need to use this type of system and will only do so if they are the ones who can write the rules regarding the functionality of the system. This includes the rules regarding access to and ultimate uses of the data in the system. 

Ideally, this new corporate entity should be not-for-profit. The business of moving information around the healthcare industry obviously can be, but does not need to be, a profit center in itself.

The new entity only needs a thin corporate structure. The intellectual property and the IT team that maintains and enhances the system remain in the corporate entity, but nearly all of the data processing and communications operations can be outsourced to a first-tier, enterprise-capable, national data processing company.  

In our team’s second pilot project, we outsourced the data processing, communications and Service Center staffing functions to Electronic Data Systems Corporation (EDS, now DXC Technology). Four first-tier national data processing companies showed interest in providing these services, including IBM, which later provided a letter of intent indicating its interest.

The level of interest that these companies demonstrated shows that a Coordinated Medical Record type of system can meet the highest levels of data and system security, stability and scalability.

Our pilot projects showed us that physicians, patients and employers are all strongly supportive of a Coordinated Medical Record system. The pilots demonstrated the ideal size and configuration of a healthcare community that make it both logistically and financially feasible to establish the system in that community.

The projects showed us that primary care physicians are the key to establishing the system in any community because they are the only entities in the healthcare industry that care for a consistent group of patients. The pilots documented specifically how the system improves the quality of care and how that quality improvement is the driver for 

multi-billion dollars’ worth of cost savings

Statistics, Reports, AI and Risk Management

The central database of Coordinated Medical Records is capable of generating real-time, comprehensive, clinical and financial, standard and customized statistics and reports that are unparalleled in the industry. The comprehensiveness and real-time nature of the information in the database make it a uniquely powerful foundation for producing artificial intelligence analyses and risk management protocols that fragmented EHR systems cannot produce.

It is critically important that this type of database be neutrally managed with strict adherence to access and use criteria that are primarily patient-, physician- and quality-focused.

If a Coordinated Medical Record system, as described, does not fit the criteria of the healthcare industry’s IT Holy Grail, then what are the criteria? Admittedly, many might argue that it would be very difficult to get this type of information system established, but no one can say that it’s impossible.

Coordinated Medical Record System's Administrative Backbone: Service Centers

How a Coordinated Medical Record system could be implemented. 

Editor’s note: This article is the eighth in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative.

The current initiative by healthcare payers to replace the traditional fee-for-service payment model with a “value-based” system is not likely to improve the quality or decrease the cost of healthcare.

The Centers for Medicare & Medicaid Services (CMS) specifically defines value-based healthcare as paying for services in a manner that directly links a provider’s performance on cost, quality and the patient's experience of care. It’s essentially a payment model that assumes that quality reports provided to CMS and private insurance carriers by healthcare providers are a good way to measure quality of care, and therefore a good foundation on which to base provider reimbursement. But there’s a problem with these quality reports.

There are more than 3,000 competing quality measures across all government and private healthcare agencies. CMS Administrator Seema Verma, MPH, has said “it’s not clear whether all of these measures are actually improving patient care.” 

Despite that uncertainty, she nevertheless said that “we need to move from fee-for-service to a system that pays for value and quality” even though “how we define value and quality today is a problem.”

To caregivers, trying to tie their reimbursement to parameters that cannot be clearly and universally defined seems counterintuitive. It’s quintessentially putting the cart before the horse.

 describes how a Coordinated Medical Record system can significantly improve the quality of healthcare by reducing the incidences of information-related problems. Decreasing the rates of misdiagnoses and inappropriate medications will decrease the incidences of duplicate tests, ER visits, hospitalizations and medical-legal issues. 

Collectively, these quality improvement measures have the potential to reduce healthcare costs by hundreds of billions of dollars — an effect that a “value-based” payment model cannot duplicate.

Despite the fact that no physician wants to make a wrong diagnosis or prescribe an incompatible medication, these problems are occurring every day at every care site across the country. It’s not because physicians are generating too few quality reports or because they’re being paid in a particular way. Payers could double their reimbursements to physicians or cut them in half and the problems would still exist because payment protocols are not the cause of or the solution to the healthcare industry’s problems.

The healthcare industry’s major problems are information-related and they need a proactive,

real-time information-based solution, not a retroactive financial solution. A Coordinated Medical Record system helps to resolve the industry’s information-related problems because it gives physicians the information they need to avoid these problems at the time of every healthcare encounter — the times and places where all of these problems are occurring.

Alternative Payment Models Aren’t Working

As of today, about 90,000 physicians who participated in CMS-sponsored advanced alternative payment programs in 2017 have still not received their bonus payments. The program’s participants typically had to make significant investments in IT systems and support staff in order to fulfill the program’s requirements, and some providers have indicated that they might actually have to make budget cuts if they don’t receive their payments soon.

To make things worse, CMS’s own analysis shows that these programs are not correcting any of the problems that it associates with the traditional fee-for-service payment model.

Because frontline physicians generate at least 80% of all healthcare activity, they are technically responsible for most of the industry’s information-related problems. By default, they are the only ones who can fix these problems.

In an environment where at least 50% of physicians are showing signs of burnout, primarily due to bureaucratic demands, long hours and EHR dysfunctionality, it seems unlikely that any initiatives that might decrease their reimbursement would be well received. Calling them “value-based” payments is not likely to convince or appease them.

A total of $35 billion was spent on an EHR incentive program that was well-intentioned, but not well-conceived. At some point there will need to be a policy shift in the healthcare industry based on the acknowledgement that fragmented EHRs are part of the industry’s quality and cost problem, not part of the solution.

Physicians, like most people, respond better to carrots than to sticks. Payer support for the development of a physician-friendly Coordinated Medical Record system that can actually solve many of the industry’s major problems is more likely to be well-received by physicians, than initiatives that threaten to decrease their reimbursement and offer no positive supportive measures in return.

The Credit Card System Is an Ideal Model for a Coordinated Medical Record System

Implementing a new record system could put more emphasis on quality of care.

Editor’s note: This article is the seventh in an ongoing series by James McGauley, M.D., on the idea of a Coordinated Medical Record system, which literally produces a single comprehensive medical record for every patient. The record contains all of the patient’s clinical and financial healthcare information over space and time. The credit card industry is the model. This type of information system will do more to increase the quality and decrease the cost of healthcare simultaneously than any other single initiative

A Coordinated Medical Record system is primarily designed to capture and organize outpatient data because 96% of healthcare encounters occur in the outpatient arena. There are about one billion outpatient visits every year compared to only about 36 million hospitalizations.

On a daily basis, there are about 2,750,000 patient-physician encounters in numerous outpatient settings across the country. By contrast, there are only about 98,000 daily admissions to hospitals. There are twenty-eight times more changes being made to patients’ ongoing medical records from outpatient encounters every day than are being made from hospital encounters.

Inpatient vs Outpatient IT and Data Management Requirements

Inpatient and outpatient healthcare settings have significantly different information technology and data management requirements.

The inpatient setting is a closed environment. All healthcare is delivered within the walls of the single institution. Massive amounts of data are captured in a short time span. Minute to hourly changes in a patient’s vital signs, temperature and medication regimen are recorded. Multiple laboratory, radiology, diagnostic and therapeutic procedure results are documented in a short time span. All of this data is technically available to all of a patient’s caregivers in the institution in real-time. It is only the discharge data that significantly alters a patient’s ongoing medical record.

By contrast, outpatient caresites are physically disconnected. They deal with a relatively small amount of data at the time of any particular patient encounter, but every change to that data significantly alters the patient’s ongoing medical record. Communication of data between caresites is delayed and inconsistent.

A Patient’s Clinical Profile: Diagnoses, Procedures and Medications

As complex as the healthcare industry seems to be, there actually is an underlying simplicity to it. The primary purpose of every patient-physician encounter is to arrive at a correct diagnosis and prescribe the correct treatment in the most expeditious manner possible.

From a medical record standpoint, the purpose of every encounter is to confirm, modify, add to, or delete the information in three specific categories — diagnoses, procedures, and medications. This is the information that populates the Face Sheet/Summary Sheet that sits in the front of every patient’s medical record. This is the baseline information that every caregiver is working from at the time of every healthcare encounter.

If this summary information is not exactly the same at every caresite, then there must be missing, incomplete or inaccurate information in the medical records at the various caresites that a patient visits. It is these disparities that lead to misdiagnoses, inappropriate medications, duplicate tests, unnecessary ER visits and hospitalizations, and medical-legal issues.

In outpatient settings across the country, the medical summaries of about 2.8 million people are being updated every day. Every time new diagnosis, procedure or medication information is entered into a patient’s record at any caresite, that information becomes the new reality for the patient, and it negates the accuracy and the reliability of the information that sits in the medical records at all of the previous caresites that the patient has visited.

By contrast, an average of only 98,000 people are being discharged from the nation’s 6,200 hospitals every day — that’s an average of only 16 patients per hospital per day. Despite the massive amount of data that is collected in these hospital IT systems, it is only the discharge diagnoses, procedures and medications that actually update a patient’s summary sheet. Because the ratio of outpatient to inpatient encounters is 96% to 4%, a hospitalization summary bears no more weight than any other single caresite encounter from the standpoint of a patient’s ongoing medical care.

The Inpatient-Outpatient Communication Gap Is Bidirectional

The problem of getting hospital discharge data into the hands of a patient’s outpatient caregivers is well documented and bemoaned, but little attention is given to the problem on the intake side — how do you get comprehensive and reliable outpatient data into the hands of hospital-based physicians?

Every emergency room physician, hospitalist, anesthesiologist, radiologist and pathologist knows that there are many instances where having access to the information in a patient’s comprehensive outpatient record would significantly improve the quality of their hospital-based care.

Based on the 96:4 ratio of outpatient to inpatient encounters, it is much more likely that hospital-based physicians would need information from a patient’s outpatient record in order to provide the best care, than outpatient physicians would need information from a patient’s relatively rare hospitalization record.

A Coordinated Medical Record system serves as a single point-of-contact for updating every patient’s medical record, whether the updates come from the high volume outpatient or the low volume inpatient side. In this capacity, this type of system assures that all caregivers are always working from the same baseline of clinical information, thus avoiding the disparities that invariably exist among fragmented information systems, and the resulting clinical and financial problems that the disparities causes.

Incentive to Establish a Coordinated Medical Record System

Despite the best patient-focused intentions of its executives, a hospital’s financial picture benefits by default from the very problems that a Coordinated Medical Record system is designed to alleviate. Misdiagnoses and inappropriate medications invariably lead to additional tests, procedures, ER visits and hospitalizations — all to the financial benefit of the hospital and its affiliated diagnostic and therapeutic services centers.

The establishment of a Coordinated Medical Record system in any healthcare community across the country is more likely to be 

driven by the community’s physicians and employers

 rather than by the C-suite executives of the local hospital-based systems.

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Making the Case for a Coordinated Medical Record System

The seventh in a series on a hypothetical CMR system to fix American healthcare. 