"Welcome to our company blog. Within these blog posts, we hope to share our insights on clinical quality management, the patient-centered medical home, chronic disease management in primary care, evidence-based medicine, and the use of technology in ambulatory care settings."

- David Morin, CEO and Donald Nease Jr., MD, Chief Medical Officer

AHRQ (Agency for Healthcare Research and Quality) recently published a wonderful paper entitled "Health Information Technology for Improving Quality of Care in Primary Care Settings". The paper looks at "the link between health information technology and quality improvement in a range of primary care settings"1. To see the document: http://healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_1248_661809_0_0_18/AHRQ_HIT_Primary_Care_July07.pdf. There are many insights and recommendations documented in this piece; if you are looking into technology and best practices to support improving quality of care, it is a must-read. But, there is a specific issue highlighted in the report that "hits home" because we constantly talk about it. Specifically: 1. Page 18 - "another aspect of data structures that continues to restrict improvement activities is the billing and reimbursement coding mindset that permeates much of health care data. For example, in many health IT systems, patients with asthma do not have a diagnosis of asthma; they have a data history of billed visits with a billing diagnosis of asthma. For visits to the clinic that did not involve their asthma (and hence no billing code of asthma was issued), there is no way to relate that visit to their chronic condition of asthma. Additionally, an asthma billing code is often used for a patient who arrives wheezing (whether they have a diagnosis of asthma or not). This may not look like a data problem on the surface, but if you ask the health IT system how many asthmatics are in a panel, the numbers are far from reality." 2. Page 19 - "data structures for billing and documentation are often very different from the data structures that support improvement" 3. Page 13 - "data that are constrained to billing codes may make it very difficult to track the progress of a chronic diagnosis over time" The paper also discusses that it may be difficult to solve this problem - but we think we have solved it through the use of clinician-verified diagnoses built from a thesaurus of coded clinical terms. We do not rely on billing diagnoses; clinicians capture patient diagnoses at the point of care based on the true conditions of a patient and Cielo Clinic stores and utilizes these diagnoses. This capture is a very simple effort and has a very small time impact on a provider. Of course, it is quite simple for our system to take a billing file and use it to pre-populate a patient database with diagnoses; we offer to do this during every Cielo Clinic installation. But, we rarely do diagnoses pre-populations as most practices are not comfortable with these data sets for clinical quality improvement. We feel strongly that a quality program built on billing data will not be successful. Bottom line, billing data serves a different purpose than quality of care data. Billing data was never constructed to support quality of care initiatives. A different data set is needed, period. It needs to be coded, clinician-verified and uncoupled from billing diagnoses. It isn't difficult to build this data set, especially with a tool such as Cielo Clinic, and build it to the benefit of all stakeholders; providers, patients and payors. Dave Morin CEO Cielo MedSolutions 1: Langley J, Beasley C. Health Information Technology for Improving Quality of Care in Primary Care Settings. Prepared by the Institute for Healthcare Improvement for the National Opinion Research Center under contract No. 290-04-0016. AHRQ Publication No. 07-0079-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2007. Page 1.

Every time an account manager at Cielo makes a presentation on Cielo Clinic, they highlight the fact that a provider can access our software either through a paper or web-based Encounter Form. For those not familiar with our product, the Encounter Form is the interface a physician uses to know what services, screening and counseling are due for a patient at the time of their visit. This Form can be delivered either via a web interface from a device connected to a network or can be delivered by a printed piece of paper. The web-based Encounter Form was designed to be extremely simple, easy to use and requires just a few clicks of a mouse by a provider. The next item our account managers highlight is that 100% of the providers utilizing Cielo Clinic access it via the the paper form and not the web interface. This includes environments that have laptops and wireless networks in exam rooms and can easily make use of the web interface. It also includes providers of all ages, even the "young ones". No one dismisses the value of the web interface, they just think that the paper form works best for their workflow. In most cases, the people at the presentation strike a curious look at that statistic and are either 1) shocked and challenge it, 2) insistent that this will not happen at their practice(s) or 3) humored by it and make some sort of dumb joke. This predisposition to use of paper in the exam room is not something that should be challenged and dismissed but instead something that should be studied. I am a big believer that the value technology can deliver is often confused by people who see it as an end result versus a means of achieving an end result. Our software is not a product that lets a physician use a laptop in an exam room, it is a solution for providing better quality of care to patients. The technology facilitates the ability to deliver this increased quality of care, but, in the end, it is the provider delivering the care, not the technology. Many people jump too quickly to the conclusion that, if only the provider used the technology "correctly" (read: uses a laptop to access everything), they would be much more effiicient and productive. What we need to learn more about is why providers feel the paper Encounter Form works best for their workflow. Does the use of a laptop or other device take away from physician-patient interaction? Is juggling a laptop in an exam room just too much effort when a simple piece of paper will suffice? Is there an emotional connection to a piece of paper that is just hard wired into humans? Is reading off a screen too difficult? There's lots of questions that can be asked, but I think we will find it all boils down to a few fundamental issues. We're studying it further and have begun to collect responses. I'll be sure to share what we find. Dave Morin CEO Cielo MedSolutions