MU Stage 3: The promise of clinical decision support for preventive care

At the risk of opening myself up to a firestorm of dissent, I’ll just come out and say it: The criteria within the meaningful use Stage 3 proposed rule for clinical decision support is long overdue.

Implementing prevention after attending to chronic disease management or even hospital readmissions is like taking two steps backward to move one ahead. 

What’s more, we will not trudge forward with the production of health in this country until prevention is brought into the daily workflow of our practices.

It’s worth noting that the Centers for Medicare and Medicaid Services lists Prevention as the number one of five clinical interventions. CMS wants us to get way upstream of disease to be effective in our emerging shared savings models and risk contracts — essentially to produce health not provide healthcare.

I see two technological methodologies by which health systems may meet the clinical decision support for intervention mandates in time for the proposed 2016 rule, those being patient portals or clinical decision support EHR modules.

Portals, of course, have been a somewhat contentious topic within the meaningful use discussion, but providers need to keep an open mind when it comes to patient engagement and portal usage. The features in your portal start with connecting patients to your office, getting callbacks or emailing your nurses, getting refills on medicines you prescribed. And implementing text reminders for visits to your office.

If your EHR has an API published that includes endpoints for true population identification, then most likely you will be able to have a care manager "prescribe" the intervention into the population's care plan within your patient portal. The rate-limiting step here then becomes the usefulness of your portal. If you can't get beyond 5 percent portal usage, then you will have a problem meeting 15 percent of patients who must self-track and receive "action" (taking a walk, for instance) and documented "user reaction" (i.e. a pedometer ticking up 3,000 steps).

I’m not suggesting this will be simple. Usability of portals and the rate of progression of the open APIs are bound to be the sticking points here. But there is a second way to implement clinical decision support interventions for those with lagging portal usability and API progression: standalone ONC-certified CDS modules.

The advantage here is that organizations can tap into emerging products that are built with a true user-centered design.

Moving forward physicians will have a "behavior change" formulary in addition to their e-prescribing formulary. Over time we can hope that the prescription of behavior change will start to eclipse the prescription of drugs. Of these products, the most important are those designed to prevent lifestyle disease, since this creates an estimated 80 percent of our healthcare costs. If we implement clinical decision support interventions for prevention thoughtfully, with compassion and caring, we will have compliance that eclipses the CMS requirements of 15 percent. Patients will use them because they don't want to disappoint us, and we will tell them we can observe and follow their usage of the tool and their user-generated biometrics behind the scenes.

Once a remote monitoring and prevention clinical decision support tool is implemented among the young of your population, returning to the office becomes something of a punishment for noncompliance, rather than the other way around. 

Patients are ready for this. Many of them like using apps to measure and improve their health and are basically waiting for us doctors to tell them to do so. Over time, once this practice becomes the standard of care, health self-improvements will be a routine part of our patient's lives.

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The digital health train is leaving the station...

After a whirlwind week at Cleveland Clinic as a newly minted member of the Startup Health Academy, followed up by demo day with the Xlerate Health Crew, we have a newfound clarity on entrepreneurship in healthcare.

We are, in fact, not alone.

Our incredible homegrown Kentucky team has exponentially grown with the addition of our international networks at Xlerate Health and Startup Health.

We join these entrepreneurs in feeling the privilege of ushering in new business models and creating markets. We just couldn't stand to keep whining about the status quo. We had to act, each of us using our own talents to their best level.

We are doers, thinkers, tinkerers, problem solvers, hackers, and last but not least, lots of doctors, in a hipster, hacker, hustler dynamic, to quote Dave McClure at 500 Startups.

Then wrap us all up in this incredible StartUp Health force, with a dream team of front men and women, Wall Street gurus, operations forces, and Ivy League connected taskmasters, and it sends chills down any old jaded primary care doctor's spine.

There might be no problem left unsolved in healthcare here.

In Cleveland, we listened CEO, Dr. Toby Cosgrove, discuss his early vision of doing cardiac surgery a different way, and his trials and tribulations along the way. Disruption always wins in the marketplace.

Forty-five 59-second pitches from StartUp Health companies blasted into the audience, back to back ushered on and off the stage like the best of Broadway productions.

Then we plane-automobiled our way down then back to Louisville, to pitch on our home turf, ushered in by the mayor of Louisville and what seemed like every healthcare CEO within driving radius.  Our peers pitched employer wellness, autism diagnostic imaging, physical therapy automation,  genetic marker discovery and advancement, home care disruption, and then last but not least some crazy entrepreneurs who want to eliminate lifestyle disease in the at-risk Robert Wood Johnson Foundation obese states.  We are two women, by the way, and a hacker.

We were glad to see at the conclusion of our Xlerate pitch, folks clapping and nodding, giving us the affirmation that 90 million people walking around with marginal A1C levels is still not an acceptable status quo.

There was a little "gasp" when we mentioned the $59 Walmart Android, its processor and the ushering in of a digital age of healthcare in 2015.  This is real and it is happening now for our patients.


Get on board. In 2015 the digital health train is leaving the station.


Natalie Hodge, MD, FAAP

CMO/Co-Founder, Personal Medicine Plus

Brandi Harless, MPH

CEO/Co-Founder, Personal Medicine Plus