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THE WORLD OF ARISTOTLE ANDPtolemy believed that Earthwas positioned at the centerof the universe. Thanksto Galileo and Copernicus’s studiesin the 16th century, we know thisis not true and that the sun is the center of our universe. Perspectives of health care haveundergone similar, radical changesin perception. For centuries wehad a hospital-centric view; anillness-based model, where the majority of care wasprovided in hospitals, when we were ill. In the lastfew decades, that model has migrated to a more continuumof care view; a wellness/health maintenancemodel, where emphasis of care is outside the hospitalin other venues such as outpatient, ambulatory/clinic,and home care (see Figure 1).But as we all know, this is still not where we needto be to support the highest quality care at the rightcost. Despite a focus on moving care out of the hospitals,one only needs to think about the process ofmedication reconciliation between care venues torealize the lack of seamless integration of care deliveryand the challenges of supporting interoperabilityacross the continuum. Hence, here I am proposing thepatient centric view, where the patient actively participatesin his or her care and we look at delivering carefrom a patient’s point of view. This allows us to breakdown some of the barriers we have struggled with onour journeys to promote higher quality care throughthe use of health information technology (HIT). Nowwe need to consider how the health care systemshould revolve around the patient, rather than thepatient rotating around the hospital. Considering apatient-centric point of view when implementing andoptimizing the use of HIT provides new perspectiveson the meaning of “integrated” health care.Patient-Centric CareIt might seem odd that a health care organizationneeds to be reminded to involve the patient in his orher care. After all, this approach would certainly besupported from a patient’s perspective. And, ofcourse, the health care industry has compelling reasonsto incorporate a strong customer and servicefocus in order to improve patient satisfaction andimpact patient loyalty. But as health care systemsPatient as Center of the Health Care Universe:A Closer Look at Patient-Centered CareJUDY MURPHY, RN, FACMI, FHIMSS, is Vice President-Information Services, Aurora Health Care, Milwaukee, WI; aHIMSS Board Member; Co-Chair of the Alliance for NursingInformatics; a member of the federal HIT Standards Committee;and is a Nursing Economic$ Editorial Board Member. Commentsand suggestions can be sent to .
EXECUTIVE SUMMARY
We need to consider how the health care systemshould revolve around the patient, rather than the
patient rotating around the hospital.Considering a patient-centric point of view whenimplementing and optimizing the use of health informationtechnology (HIT) provides new perspectiveson the meaning of “integrated” health care.Not only do we need to give patients the opportunitiesto participate as true partners in their health care,we must convince them why this partnership makessense.We should not be naive and believe all patients wantthis involvement in their care today and are ready todo all their health care transactions electronically.But considering and using these practices are importantsteps in the health care reform journey toimprove quality and decrease cost.Many patients will benefit by our working with them todemystify the health care experience through patientcentricpractices and the use of HIT.Information Systems & Technology
Judy Murphy
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have grown more complex and fragmented, and as clinicianshave felt pressured to be more productive,care has become more centered around the needs ofthe system – often at the patient’s expense.Patient-centric care includes the patient and heror his significant others as an integral part of the careteam. They collaborate with health professionals tomake decisions about their wellness and illness care.Patient-centered care encourages patients to takeresponsibility for important aspects of their preventiveself-care practices, as well as any disease managementstrategies and monitoring. Patient-centric carehelps the flow between health care settings be moreseamless, as the patient is an active participant andthe health care providers are paying attention to theneeds of the patient. When care is centered aroundthe patient, opportunity exists to remove unneededand unwanted services. So, just how can technologyhelp to support patient-centric care and help improvepatient outcomes? Let’s investigate four practiceswhere technology can help.
eHealth
The HIT industry has just begun to tap into thepotential of eHealth and the value of patients participatingin their own care using web-based tools. Oftenthis is seen as a “self-service” option, and possibly asa productivity enhancer for the health care organization.But, opening our registration systems and schedulingbooks so patients can arrange appointmentswhen it is most convenient for them serves the moreimportant purpose of demonstrating they are truepartners in their care. Further, to have patients updatetheir demographics, insurance, allergies, and medicationlists puts the accountability for the accuracy ofthis information, not only where it belongs, but wherethe source of truth lies. This is, of course, the underlyingprinciple of Microsoft’s HealthVault, GoogleHealth, Relay Health, or other personal health records(PHRs) tethered to a health care organization’s electronichealth records (EHRs), where patients createtheir own account and store their personal healthinformation in a health record bank.There is no other part of the human experiencewhere such a passive role is played as patients managingtheir own health care. This needs to be turnedaround if we are to reach the next level of care quality.It is the patient who is the constant across the carecontinuum. By focusing on the patient, and not thecare venue, we can create the seamless integrationneeded to provide the best care.This area has one of the largest potentials forimpacting the quality of health care. Online storage ofimmunization records, advanced directives, medicationlists, medical histories, and a cadre of other pertinentmedical information just makes sense andallows the patient and practitioner to access them anytime from any care venue. Furthermore, computegeneratedhealth maintenance and disease managementreminders can support the evidence-based careall clinicians strive to provide. Our challenge is clear:not only do we need to give patients the opportunitiesto participate as true partners in their health care, wemust convince them why this partnership makessense. But as their advocate, that is our job, too.Nursing has a long history working as thepatient’s advocate. In this case, we need to work withour patients so they can understand the importance oftheir participation as a partner in their care, instead ofplaying a passive role. One way we can do that is toencourage our patients to actively use a PHR to managetheir own health care and to partner with theirhealth care providers.Primary CareLittle is known about the extent to which primarycare physicians support or practice patient-centeredcare, which is one of the Institute of Medicine’s (2001)six dimensions of quality. A Commonwealth Fundstudy (Audet, Davis, & Schoenbaum, 2006) of patientcenteredpractices by primary care physicians focusedon 11 specific patient-centered care practices: samedayappointments, e-mail with patients, remindernotices for preventive or follow-up care, registries ofpatients with chronic conditions, patient medicationlists, electronic medical records, information fromreferral physicians promptly available, medicalrecords/test results readily available when needed,patient survey data fed back to practice, patient ratingsof care affect compensation, and information on qualityof care of referral physicians available. Theresearchers rated physicians’ patient-centered practicescores as low, medium, or high based on how many ofthese 11 patient-centered care practices they adopted.Twenty percent scored in the low range (0-2 practicesadopted), 58% in the medium range (3-5), and 22% inthe high range (6-11). Actually, these results aren’t toobad, but automation in the physician office couldimprove these patient-centered practices even more.This same study documented that only 16% ofprimary care physicians used e-mail to communicatewith their patients, 74% experienced problems withthe availability of their patients’ medical records ortest results, and only 50% had adopted patientreminder systems. Imagine if the physician office wasfully automated with an electronic patient recordintegrated with a patient portal for eHealth. First andforemost, the patient’s medical record would alwaysbe available. Results and reminders would be generatedelectronically and sent to the patient. The patientcould respond with questions, and document otherresults for the physician. A good medication listcould be co-owned and maintained. It is easy to seehow shifting the focus to the patient and away fromthe provider or clinic system could impact patientcare and satisfaction in a positive way.
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The Patient Centered Medical Home (PCMH)model in primary care promotes patient-centered careby facilitating a partnership between individualpatients and their personal physicians. Care is facilitatedby registries, information technology, healthinformation exchange, and other means to assurepatients get the indicated care when and where theyneed and want it in a culturally and linguisticallyappropriate manner. The National Committee forQuality Assurance has published PCMH standardsand has a recognition program for primary care practices.This is another way to encourage the patientcentric model and patients’ participation in their care.Hospital CareFocusing on the patient is not a new concept for theinpatient setting, and probably is the venue that has therichest history of incorporating patient-centric carepractices. But even here we can enhance the patientexperience by using echnology to enable the hospitalizedpatient to participate more fully in his or her care.What if hospitals implemented change-of-shiftwalking rounds with computers-on-wheels, usingonline shift report or task lists to remind patients ofwhat went on during the previous shift and informthem of what is to come on the next shift? What abouta computer-generated “itinerary” of patient activitiesfor the day, so they know what to expect from lab,nursing, and radiology, and can participate more fullyin their care? Why not include interactive patientteaching modules patients could complete throughthe TV? What about including patients on their ownoutcome facilitation team, having them participate indischarge planning rounds, or having them helpupdate their online care plan? Patient outcomes canonly be better if they know what we are working onand can actively participate with us.Health Information ExchangeOne of the most important changes to improvecare coordination and create a patient-centric healthsystem in the United States is related to the ability toexchange health care information between all carevenues: hospitals, clinics, physicians, home care, andpharmacies. Of course, moving paper health recordsaround would never adequately serve this purpose, sothis initiative has been directly linked to EHRs. Thereare local, regional, state, and federal initiatives underwayto create the foundation and implementationspecifications for data interoperability between allcare venues and between varying EHR systems.Significant parts of the American Recovery andReinvestment Act’s HITECH funding has gone towardadvancing the interoperability and portability of electronichealth records. This includes sharing HER information with the PHR.Imagine if a patient’s problem list, family history,medication list, allergy list, and vital signs werealways available to any care provider in any location.Imagine if the patient’s lab data, last chest x-ray, orlast mammogram result were readily available duringa followup exam. Imagine if all histories and physicals,consults, outpatient reports, and discharge summarieswere accessible. There would certainly be lessrepeats of tests because previous results were notavailable, and there would be better care decisionsbecause data would be available. These are practicesthat focus on the patient and promote patient-centriccare, enabled by HIT.
Summary
The federal EHR Incentive Program identifiedmany of the principles discussed here in the criteriato qualify for “meaningful use” of certified HER incentives. Two of the five meaningful use initiativesincorporate specific objectives focused on patientcentriccare: engaging patients and families, andimproving care coordination. This includes ensuringthe EHR can customize delivery of information to thepatient, provide an electronic copy of dischargeinstructions and a summary of care, as well as theability to electronically transmit health informationfrom one care venue to another.We should not be naive and believe all patientswant this involvement in their care today and areready to do all their health care transactions electronically,but considering and using these practices areimportant steps in the health care reform journey toimprove quality and decrease cost in the UnitedStates. Many patients will benefit by our help indemystifying the health care experience throughpatient-centric practices and the use of HIT. $
REFERENCES
Audet, A.M., Davis, K., Schoenbaum, S.C. (2006). Adoption ofpatient-centered care practices by physicians – Results from anational survey. Archives of Internal Medicine, 166, 754-759.
Institute of Medicine. (2001). Crossing the quality chasm: A newhealth system for the 21st century. Washington, DC: Author.