Achieving “systemness” through cloud-based EHRs

Pay-for-Performance (P4P) has been a compensation model increasingly used to reward physicians and healthcare organizations for achieving specific health-quality goals. Medicare (CMS) has developed a set of criteria (PQRI) designed to reward individual physicians and practices who achieve high marks on a set of metrics for Medicare patients (in addition to fee-for-service payments). Similarly, private HMO insurers have used a similar set of criteria (HEDIS) to reward physicians taking care of their HMO patients.

In California, P4P has a fairly long history, and is a feature of performance-based compensation paid at the group level to risk-taking accountable physician organizations (medical groups and IPAs). The Integrated Healthcare Association (IHA) has been a California-based forum where stakeholders (medical groups, insurance plans and hospitals) agree to a standardized P4P criteria set to be used by everyone.

The IHA criteria set is divided into a variety of domains: (1) clinical, largely drawn from HEDIS criteria; (2) patient experience, measured by patient-satisfaction surveys; (3) clinical IT “systemness”; (4) care coordination (specifically in diabetes); and (5) efficiency.

The IT-enabled “systemness” domain is of particular interest, since it overlaps considerably with presumptions around Meaningful Use being carried out on a national level by the ONC’s HIT Policy Committee. The IHA criteria for “systemness” includes (1) Data Integration for Population Management (reporting of diseases and conditions electronically); (2) electronic clinical decision support; (3) Care Management – i.e., coordination among practitioners, chronic care management, and continuity of care; (4) physician measurement and reporting. The ability to do these things electronically is central to the Meaningful Use discussion that have occurred to date. They are also very difficult for an individual practitioner to accomplish, absent a robust EHR system. Given that the IHA criteria are focused at risk-taking groups, this domain is a test of how well the group can function with group-level IT.

What kind of technology can support this level of care coordination – where clinical information can be shared between practitioners, decision support can be included at the point of care, and reporting can be done comparing physician performance to community or national averages? Stand-alone, locally-installed client/server EHRs will have a hard time rising to this bar. Why? Because the data created remains isolated, in a silo, separate from others. This is why, traditionally with locally-installed EHR systems, such reporting and comparison to peers, as well as care coordination between practices, has only been accomplished at a group level, with group-level IT.

However, SaaS-based, “cloud”-oriented EHRs like Practice Fusion offer the promise to achieve this type of integration even to solo practitioners. By hosting the data centrally, there is the potential for clinical data sharing between practices, delivering decision support to the individual physician’s desktop, and creation of health-quality data reports so that a physician can compare his/her performance relative to peer groups. In fact, this basic approach to EHRs (“cloud” based systems) will achieve this desired level of interoperability much sooner than the traditional road, where localized data islands need to build complex bridges between them (through the evolution of Health Information Exchanges, or HIEs). The HIE infrastructure is being built, at great expenses, and to date has not been used meaningfully – though that is a hope for the future. The promise of real “systemness” will become a reality much sooner with an Internet “cloud” approach. Stay tuned and watch as Practice Fusion delivers on this potential!


Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.