Navigating Healthcare – Patient Safety and Personal Healthcare Management

Process matters as much as technology

Posted in CMIO, EMR, Healthcare Technology, HealthIT, HIT, Innovation, Technology by drnic on September 22, 2015

Hope you can join me and my fellow Medical Informatics friends:

R. Dirk Stanley, MD, MPH @dirkstanley
Luis Saldana, MD @lSaldanaMD
Luke Webster, MD @LukeWebsterATL
Rasu Shrestha, MD, MBA @RasuShrestha
John Mattison, MD @JohnEMattison

 

for our inaugural #CMIOChat on Thursday September 24 at 4pm ET (Regular Chat 3rd Thursday of every month) 

Here’s the post for the topic we will be covering Emerging Technologies and questions around the technology that might be critical for success, what factors are helpful to consider when prioritization technology adoption and how to keep your IT department prepared for the future

 

It’s an exciting time to be a chief medical information officer (CMIO), especially at a hospital or health system with forward-thinking leadership. New technologies are emerging that will help us make huge strides toward truly effective, precise and personalized medicine.

That said, it’s also a very complex time. New technology comes with a host of challenges, and the biggest lie not so much with the technology but with the people involved. New clinical technology inevitably disrupts established workflows, and while it can be a big improvement, it has to be handled carefully if you want the project to succeed.

Over the past five years, as EHR adoption has soared, we’ve seen spectacular successes and spectacular failures in technology adoption. The difference between the two often lies in the process, training and the implementation services used.

So what makes for a good process? Discipline, for a start. You want to move forward with all deliberate haste, but you don’t let yourself be pushed into taking shortcuts or unjustified leaps of faith. Too many projects have gone down in flames because a good process was circumvented in the haste to meet an arbitrary deadline or at the behest of an impatient leader. As the strategic technology leader for your organization, you set the standard for how projects are planned, implemented and measured. If you are disciplined, others will follow your lead.

No matter what the technology, there are a few key factors to focus on to increase your chances of success. Below are the ones that I think make a big impact. Some are obvious, but there are organizations that have ignored the obvious and lived to regret it. Take heed.

Know where you are

Before you launch a project (before your even plan a project), know your organization and its capabilities. Don’t assume you know what’s happening on the nursing units just because you meet regularly with the nursing leadership. They may not know what’s happening and impacting day to day work on the nursing units. People get very creative with workflows when time is short and they feel the pressure to do too much. If you are introducing technology that will affect a particular area, take the time to talk to front-line staff, with a particular eye to understanding the process variations that exist.

Same thing for the technology. Don’t base all your knowledge on what the CIO reports. Talk to the data center manager and the front line IT staff to learn the variations that occur to the set protocols. They will also be aware of how well their end users are following security protocols, which is knowledge you should have before you introduce new technology.

Think carefully about all the stakeholders, and take the time to understand how those stakeholders currently do their jobs.

Know where you are going

Make both a clinical and business case for any technology you want to adopt. Have clear and realistic goals. Avoid the temptation to oversell the merits of the new tools, because if the results fall below the expectations, things will get very uncomfortable for you and anyone else who has championed a project. Don’t undersell, but be sure to set achievable goals.

Also, get the metrics for a full year of operations prior to the adoption of the new technology, to have a reliable baseline for monitoring performance. Why a year? Because that will show any seasonal variations as part of a continuum. If you use a shorter window, you might inadvertently have data that is either on the top end or the bottom end of a variation, which could skew your view of results.

Gain from lessons learned

If others have blazed the trail before you, talk to them – use social media or join a TweetChat like #CMIOChat for example. Find out what mistakes they made, what challenges they saw and what factors were most important in making things work. Were there unintended consequences or unanticipated benefits?

Plan carefully

As you start the process, get all the key stakeholders at the table. Make sure you have input from the people who will use the technology most. That means frontline staff as well as leaders. Make your timeline reasonable, and do a pilot launch of the technology in parallel with your usual operations. That will allow you to test and refine before you go live. Even seemingly small changes can have big impact, and testing will uncover all those unintended consequences that could trip you up.

Don’t forget the business operations in your planning. One large system saw a huge drop in revenue when they implemented a new EHR in 2013, because it changed where and how charge capture occurred. Millions of dollars were lost over several months while they tracked down the problem and retrained staff. So if your new technology changes charge capture in anyway, you’ll need to plan for that. Your colleagues in the business operations arena must be involved.

Get the right resources

Don’t assume that you have all the expertise in-house to plan and implement a new technology. You can often save money in the long run by investing in consulting services and short-term staff augmentation to assist your people with the planning and implementation. Your staff have to keep the business running, while these contracted experts can focus solely on the project. If you choose your vendor wisely, you will have access to knowledge gained from hundreds of other engagements. And they will bring a disciplined process to the project, one that has been refined over many iterations and in widely varying environments.

But don’t just hire folks and walk away. Stay involved. Treat the consultant as a partner, and work together. Take advantage of the experts’ knowledge, and offer your own knowledge of the organization to improve the planning and implementation.

Choose your champions carefully

Physician and nursing leadership are often critical to successful technology adoption. The right champions can make or break a project. Choose these people based on their influence with their peers; their ability to be enthusiastic without being unrealistic; and their ability to take a disciplined approach to a project. An enthusiastic champion with no follow-through abilities can create cynicism and distrust. Conversely, don’t choose people who are so nit-picky that they slow things down over unimportant details. Common sense and an optimistic frame of mind are the key attributes you want. Plus a thorough-going knowledge of the clinical issues involved.

Start small and be both willing to fail and persistent

New technology inevitably requires trial and error. Failure is okay, if it happens small and early and is well documented. Do pilot projects before you take on a big one with new technology. Test, learn and test again. Don’t abandon a project without knowing exactly what went wrong and why. That process of examination can often identify a new approach that will lead to success.

In a TED talk on the subject of trial and error, Tim Harford (@TimHarford) notes that all really good complex systems are the result of trial and error. But it has to be disciplined trial and error, with results carefully documented and each failure examined for lessons that guide the next attempt.

Don’t be on the tail end of technology

In 2005, Blockbuster dominated video rentals. By 2010, the company filed for bankruptcy, its business model disrupted by Netflix’s streaming video and Redbox’s rental kiosks. Other brick and mortar businesses also declined, their profits eroded by Amazon, e-Bay and other virtual markets that offered responsive service and convenience.

Healthcare faces a similar turning point, in which the delivery of healthcare is radically changing. With the emergence of disruptive technologies like telehealth and retail express clinics, consumers want a different healthcare experience, one in which they have greater control, engagement and convenience.

So don’t be Blockbuster. You don’t have to be Netflix, but you don’t want to stick your head in the sand and wait to see what happens. If you are disciplined in your research, planning and expectations, and you have a well-thought-out business and clinical case for a new technology, move forward. The alternative is to fall behind and become irrelevant. And our patients can’t afford for us to give them half-measures.

 

This post originally appeared on CMIOChat: Process matters as much as technology, especially when treading new ground

Process matters as much as technology was originally published on DrNic1

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Connected Health and Accelerating the Adoption of #mHealth

Posted in #hcsm, #mHealth, bigdata, EMR, Health Reform, HealthIT, HITsm, Medical Devices by drnic on November 7, 2014

I attended the Connected Healthcare Conference in San Diego yesterday Accelerate mHealth Adoption: Deliver Results through Data Driven Business Models for End-User Engagement

Never has there been so much to play for in the mobile health landscape, a revolution is just round the corner with key players from the health care and consumer markets coming together to develop the mHealth industry. This Connected Health Summit will create a bridge bringing together hospitals, clinicians, providers, payers, software and hardware innovators, consumer groups and the wireless industry.

You can find the agenda here and the organizers will be publishing the presentations – there were many interesting insights

Andrew Litt, MD (@DrAndyLitt) (Principal at Cornice Health Ventures, LLC) opened the conference with a great overview of the industry and a slew of challenges and opportunities.

He sees our industry in Phase 1 – the Capture and Digitization of records and we have yet to really move and explore Phase 2:

Move and Exchnage Data AND Analyze and Manage Data that is linked to Information Driven decision Making

And Phase 3:

Managing Patient Health

In our need to move from data to analysis and information he cited a statistic from a white paper: Analytics: The Nervous System of IT-Enabled Healthcare that sadly puts 80% of data in the EMR unstructured. This is a fixable problem today with Clinical Language Understandingand we are seeing some results and a change in the industry to stop looking to doctors to be data entry clerks He also cited Hospitals:

Technology offers tremendous scope to not only fix these problems but get ahead of the problem (as is done in other industries like the Airline industry that has rebooked your flights before you even land and miss your connection). As he suggested could we use data to understand who is likely to develop a heart attack in the next 2 hours and try and change this outcome

But integrating mHealth into our workflow requires an mHealth Ecosystem:

mHealth needs an ecosystem that improves workflow and integrates data to reduce clinicians workload. This is why doctors and clinicians are resisting mHealth – they don’t like the change to the workflow that has little if any positive effect (for the doctor – they may have a positive effect for the individuals health) of reducing clinicians workload

Interesting comment on wearables and the perspective of doctors on these devices:

What bothers the doctor – mostly the people who are buying and using wearable fitness/activity trackers are the people that are young healthy fit and want to prove to (themselves/others) that they are young fit and healthy?

His graphic on Security and privacy was on the money:

Essential to balance Privacy of Health with interoperability but trust is the imperative The stats he presented were troubling (at best)

  • 96% – Percentage of all healthcare providers that had at least one data breach in the past two years
  • 18 Million – Number of patients whose protected health information was breached between 2009 and 2011
  • 60% – Proportion of healthcare providers that have had 2 or more breaches in the past 2 years
  • 65% – Proportion of breaches reported involving mobile devices
  • $50 – Black market value of a health record

The healthcare industry is under attack and is the most attacked industry today:

You might find these figures of the value of Healthcare data as it is valued on the black-market

Another interesting data point:

HIMSS records a total of 11,000 Healthcare Technology companies – less than 100 are large size and the balance of 10,900 are small business that are essentially capturing and scattering your data across many systems and data repositories…

Multiple other presentations and panelists that were all insightful. As always Jack Young (@youngjhmb) from Qualcomm Life Venture fund had some great insights – impossible to capture all of them but here are some:

Healthcare is moving out of the hospital into the home for many reasons but cost is a big driver:

and he suggested there was at least $1.5 Trillion in economic value as the industry shifts (shifting vs replacement?)

 
 

Many were surprised by his stat that users check their smart phone at least 150 times per day (just looking around my world this seems low) – in fact a quick check online suggests this is no longer valid and it is probably 221 times per day. Given this device is the one thing we will not leave home without and it now contains a range of sensors including:

  • Accelerometer
  • Gyroscope
  • Magnetometers
  • GPS
  • Cameras
  • Infrared
  • Touchscreen
  • Finger print
  • Force
  • NFC
  • WiFi/Bluetooth/Cellular

We have the potential for more passive compliance with our patients (and as many stated in their presentations likely more accurate as self reported data is notoriously inaccurate) He predicted a a 10x growth in wearables from 2014 – 2018 with 26% of this growth attributable to smart watches (I know hard to believe at this point but I think if you looked back 4 years ago the iPad had nothing like the level of penetration it does today) iPad Growth Rate

I liked his assessment of the werable market place by researching the eBay Discount against the price of the new device:

and even worse for Smart Watches

I also presented “mHealth Reimbursement – Who Will Pay: You can see it here at Slideshare or below:

mHealth Reimbursement : Who Will Pay? from Nick van Terheyden

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Speech and the Digital healthcare Revolution at #SpeechTek

Come join me in the conversation with my colleagues at the SpeechTek 2014 conferencein Marriott Hotel in Time Square, Manhattan New York.

The Panel: C103 – PANEL: The Digital Healthcare Revolution at 1:15 p.m – 2:00 p.m. The panel moderator Bruce Pollock, Vice-President, Strategic Growth and Planning at West Interactive and on Social Media @brucepollock

I will be joined by Daniel Padgett, Director, Voice User Experience at Walgreens and on Social Media at @d_padgett and David Claiborn, Director of Service Experience Innovation at United Health Group.

We will be discussing the opportunities and challenges associated with the current digital healthcare revolution and of course how speech plays an essential role in integrating this technology while maintaining the human component of medicine that we all want. Rather than Neglecting the patient in the era of health IT and EMR

We have progressed from the world of Sir Lancelot Spratt

And the Doctor need to look at the patient not the technology perhaps in a cooperative Digital Health world like this

Is this future of Virtual Assistant Interaction good, desirable

Demo Video 140422 from Geppetto Avatars on Vimeo.

We will be discussing

  • What are the biggest obstacles to digital healthcare becoming a reality?
  • Where do speech technologies bring the most value to healthcare?
  • How will health providers, insurers, and payers provide patient support in the world of digital healthcare?

Perhaps the emerging Glass concepts improve this interaction as they are exploring in Seattle

Join us for analysis of the state of digital healthcare today and predictions for its future.

In the end

People forget what you said and what you did but they remember how you made them feel

Come join the discussion as we explore the digital technology and how it should be used in healthcare and how speech can help

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Getting Value from the EHR – Yes it is Possible

Posted in #hcr, #hcsm, Art of Medicine, EHR, EMR, Healthcare Technology, HealthIT, HIT, HITsm by drnic on July 18, 2014

I have the privilege of spending a lot of time on the road interacting with clinicians around the country (and world). I hear with too much frequency many doctors complaining about the Electronic Medical Record and how it fails to help them and in many cases makes their work harder. Some of this is a hangover from the past and the inadequate technology and in some cases hardware at the time In fact I’ve told this story a number of times that I can date to around 1995/6 and in this piece: Clinical documentation in the EHR

Many years ago, an excited friend who worked for one of the electronic health record (EHR) vendors at that time — it was really more of a billing and patient tracking and management system than an EHR — was desperate to show me some of their latest applications. In particular, a new module they had developed to capture clinical data. My friend pulled out his laptop, fired up the application, selected a patient and proceeded to enter blood pressure (BP). Some 20-plus clicks later, he had entered a BP of 120/80. While he was excited, I was dumbfounded. When it comes to patient care, doctors didn’t have time for 20 clicks to record BP years ago and they definitely don’t have that luxury in today’s demanding medical environment.

There is still some of that going on and not enough focus on the User Interface design and turning the technology into a barrier – this is the focus of the Art of Medicine campaign we launched some weeks ago

This article on Government HealthIT Are electronic health records already too cluttered? highlights a rising problem and one I hear about frequently. This is not just a healthcare problem and it is the focus of the work by Edward Tufte an American statistician and professor emeritus of political science, statistics, and computer science at Yale University who is well known for his books on information design which are bets acquired by attending one of his frequent courses on data visualization Here is a recent overview of visualization on the iPhone

He has a section on healthcare but many of his principles apply

For Brian Jacobs the problem was even more acute working in a Pediatric ICU:

The ICU is a very toxic and tech-laden environment….because of that, it offers the opportunity to make a lot of mistakes

As he points out much of the cutter derives form the multiple notes entered into the EHR every day. “It’s not uncommon in teaching hospitals to have six to seven notes per day on one patient, by the time the attending physician, residents, consultants, other doctors and fellows check on the patient.” So they instituted a policy of One Note per day

Actually its

It’s actually one note per team per patient per day; one giant multi-contributor note. They still may be all writing their components, but it’s one note

With a template to hold the content generated each morning by the resident and then everyone contributing to that one note, adding and amending as necessary

So in addressing the issue clutter they also addressed usability and design turning the note into a living breathing document that is updated and maintained by the team that now takes care of patients But he addressed some other important issues – especially when it comes to quality of care and the quality of the medical note

Copy Forward is subject to some warranted scrutinyfrom a billing and audit standpoint. Much of the repetitive and “clutter” in the note comes form the copying forward of past information. But:

These notes should never be the same

And as part of that message they moved to an “End-of-day note” that was a fresh summary of the patient. Add to that an updated and well maintained Problem List and integration with the billing system to allow doctors to select their code for the work carried out that day and they moved to a valuable addition to the healthcare team in delivering quality healthcare with their EHR

EHRs are: more complete, legible, accessible and can be auto-populated and searched. They can provide diagnosis codes and they’re good for billing. On the other hand, they can sometimes lack quality information and are by far, too cluttered.

I said this back in 2003 (yikes!) – The Future of Technology is already here – Who’s on Board the train and who’s left at the station. I still believe it and understand that the technology does need to get better and be more integrated into the existing workflow

The next generation of health care technology is here, with visionaries and futurists pushing the envelope to enhance, create and generate the newest cutting edge in health care delivery. Advances in technology, like advances in medicine, are a shared entity that enhances life expectancy and the quality of life.

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Patients Prefer Electronic Documentation

This Survey: Do Patients Really Care if You Use Your EHR in the Exam Room? was very revealing. It turns out contrary to the perception that the intrusion of EMR’s in the office patients prefer electronic documentation to alternatives

Most Patients Don’t Mind Electronic Note-Taking During Exams

In each case, more than 80 percent of respondents indicated they would not be bothered. On a sliding scale, patients indicated the least concern for doctors using tablets during the exam.

What was more surprising was the push back by patients on having scribes

But worst of all – recording devices

Ultimately, over one-third of patients said they’d be bothered by doctors using tape recorders to assist in charting medical notes. Specifically, patients at the furthest end of the spectrum—those who chose “would bother me a lot”—were more prevalent when it came to tape recordings than with any other method of charting during an exam.

There was a big preference to Electronic documentation at the point of care

They asked about reasons for dissatisfaction

Its not the technology that causes the dissatisfaction but in order of importance (for patients)

  • long wait times at the doctor’s office,
  • unfriendly staff
  • short duration of visits with the doctor
  • Trouble Scheduling Appointment

And coming in with a sliver of dissatisfaction at 5% “Doctor using a Computer in the exam room”

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The Art of Medicine CIO Breakfast – What Needs to Change to Get Doctors Back to the Patient?

Medicine is part science…. Part art.

The relationship between physicians and patients is at the core of healing. This begins with hearing and understanding. We want to reimagine healthcare—where physicians can get back to the art of medicine and were delighted to be joined by panelists:

Dr. Mark Kelemen, Senior Vice President, CMIO, University of Maryland Medical System Dr. Charles H. Bell, Vice President, Advanced Clinical Applications, Hospital Corporation of America (HCA) Stuart James, CIO, Sutter Health Dr. Andrew Watson, CMIO, University of Pittsburgh Medical Center (UPMC) (@arwmd)

The panel was moderated by our very own Dr. Paul Weygandt, Vice President, Physician Services, Nuance Keith Belton, Senior Director, Clinical Documentation Solutions Marketing, Nuance

and attended by some 50 attendees with varying backgrounds and perspectives

The underlying question:

How do return the focus to the patient. How can physicians navigate the changes and challenges of today’s complex healthcare environment while doing what matters most to them – listening and caring for patients?

The panel discussion addresses current physician frustrations with technology and what needs to change to keep them focused on patients and not data entry. It was clear that the physician’s voice and medical decision making is what matters most in practicing the art of medicine and how do physicians and patients both benefit?

 We know from surveys that

  • 36% of physicians say that EHRs interfere with face-to-face communication during patient care
  • 80% of physicians say “patient relationships” are the most satisfying part of practicing medicine
  • 28% of an average ER physician’s time is spent directly with patients
  • and from a recent HIMSS session interesting Patients prefer doctors to have an EHR
This is about the changing face of healthcare – it’s not just about technology. It’s about how we envision healthcare. How do we explain to providers that this isn’t about technology – this is about a new world order coming to healthcare

Posting every patients Magnesium level multiple times in a note is not good clinical care #artofmedicine #himss14

One of our panelists asked the audience:

How many Docs would go to facility with no #EMR and used paper – no hands went up

We do see value in Health Information Technology
 

One of the overriding concerns was the need for cultural change. The office or hospital based physician system is struggling to meet the patient needs today. They want to have the right nurse or physician there for them at the right time and indeed at the right place with telemedicine. It’s about cloud-based/consumer-based healthcare.

More consumer-friendly healthcare

We need to get back to that local physician practice – with technology in the middle as a supporting actor but not the main event

Technology cannot be an impediment to taking care of patients
 

Many physicians are in this field because we are trying to drive change but are struggling with the existing system that fail them. When I see a patient I have to review 10 systems, carry out at least 4 major systems examinations before I can submit a claim that properly reflects the care I delivered:

 I am not taking care of the patient I am taking care of a computer

Dr Andrew Watson told the story of a patient under his care with a terrible antibiotic resistant infection that a patient developed in hospital and he was now under constant supervision adn intensive therapy. But as he said – he never needed to come into hospital – he could have been treated at home. Poignant reminder that Telemedicine is not just about reducing cost – it can be better for the patient and offer better results.

Dr Bell is waiting for the MIDI (musical instrument digital interface) moment so that he can plug into the medical record and go.

As a musician he remembers the implementation of the MIDI interface in the early 1980’s that allowed music manufacturers to create one standard that was royalty free and widely adopted for the benefit of the user musicians and the vendors. He wants that in healthcare – so do I.

Until we change the mandate on clinicians to document 8 of 10 systems to be fairly compensated for the care given  

And importantly the concept of Bring Your Own Device (BYOD) is bringing functional tools into the healthcare setting and will/is revolutionize the care being delivered. As one panelist put it:

my iPad never complains, is always there, has the latest information and access to latest medical updates
 

To summarize:

  • We need strategies for bringing the focus back to the physician-patient interaction and removing impediments to that relationship
  • Healthcare organizations should be and are encouraging/valuing physician professionalism
  • This is about the changing face of healthcare – it’s not about technology. It’s about how we envision healthcare. How do we explain to providers that this isn’t about technology – this is about a new world order coming to healthcare

Come join the conversation at The Art of Medicine or come to the panel session Thursday, March 27, 2014, 9:00 – 11:00 am EST at the W Hotel,100 Stuart Street, Boston, 02116

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Clinical Documentation Lifeblood of Healthcare

Awesome video put together showcasing the various aspects of clinical documentation and why it is so important to capture the complete patient story in narrative form

Putting all the details means capturing the diabetes and loss of consciousness

Everything from Assure and the ability to capture anywhere and the exploding area of mobile integration of voice and all the follow up in the back end for HIM

Doc Tornado’s Quest for Clinical Documentation

Posted in Clinical Documentation, EMR, HealthIT, Speech Recognition by drnic on February 13, 2013

CLINICAL DOCUMENTATION


NOW I’LL TELL YOU WHAT I WANT, WHAT I REALLY REALLY WANT
Enough bitching like a Spice Girl, it’s time to structure my wish list and share it with you, dear vendors. Let’s start with my favorite topic if you don’t mind: Clinical Documentation and Data Input.

So here’s my story from A to Z…if you wanna get with me, you gotta listen carefully.

In his review of what he really really wants Doc Tornado’s laid out his requirements that include….choice
No one size fits all and failure to provide clinicians choice is a recipe for problems

Sometimes a form fits, sometimes it doesn’t. And of course includes the range of speech tools from mobile dictation to speech recognition that offes flexibility between, as he puts it

On my end, I’ll feel like front-end on Mondays and back-end on Fridays

It should include intelligent understanding and interaction.

The good news is much of this is here today both in terms of the choice for the technology but also the intelligent interaction. This teaser video gives a good sense of what’s possible:

So I would say that’s “Alohomora”:

Come visi our booth at HIMSS to see this in action at Booth 4025 (view a floor plan here

Digital Health Needs To Be More Than Just Digital Data

Posted in bigdata, EMR, HealthIT by drnic on February 6, 2013

This last week – the widely read Dr. Rob Lamberts lamented the usability of his Electronic Medical Record (EMR) software for his new primary care practice. It’s worth reading (here) as it highlights the larger systemic problem of EMR software generally and then specifically as EMR software is overlaid onto a new payment model.

In Dr. Lamberts case, a software solution – one that was built specifically around billing mechanics (namely ICD-9 and CPT “codes”) – was overlaid onto a new practice model that bills patients a flat monthly fee for “all-they-can-eat” primary health care. Almost all EMR/EHR software has been purpose-built to support billing as the primary function. Clinical data capture is the secondary objective – and the EMR/EHR software vendor landscape is 100% reflective of that priority (as is the entire system). At last count, there were over 600 EHR “vendors” and over 300 that had reported at least one doctor or practice that ”attested” to “meaningful use” with their software (a requirement for HITECH Act payment). To date, we’ve spent over $10B on “digitizing” health records.

I’m struggling to find the right analogy, but I imagine the effect Dr. Lamberts (and others) are feeling is similar to putting a V-8 engine onto a bicycle. Yes, you could (conceivably) engineer that solution – but why would you – and then why would you expect any kind of usable experience? You simply wouldn’t (unless, perhaps, you were Evel Knievel). Even Felix Baumgarten carefully employed a team of 300 (including 70 engineers and doctors) in his lone (and breathtaking) leap from the edge of space.

Forbes colleague David Shaywitz wrote more broadly (and brilliantly) about this in his piece earlier today: Handle With Care: Success of Digital Health Threatened by Power of Its Technology. This too is well worth worth reading as it relates to the “quick-fix” mentality that is pervasive in both our culture and our wheezing health care system. It’s everywhere – and short-sighted. For providers, let’s cram-down EHR solutions so that we can “capture” the downstream data/analytics that we so desperately need to control costs – with little interest, attention or concern to the consequence on the front-end patient dynamics (including both patient AND provider experience). For employers, let’s add “gamification” and “wellness” programs (with “behavioral economics” of course) to the HR/Benefits equation. While we’re at it – let’s automate low-acuity, primary care as much as we possibly can. There – all done. We’ve digitized, gamified and automated the whole mess.

The effect – as evidenced by Dr. Lamberts plight (and flight) – is to eject altogether. The fundamental hope (and risk) of this “direct-to-consumer” model is that personal (and fiscal) sanity will return to the private (often solo) practice of primary care. I’m not sure it’s the right hope (or exit), but I do understand the motivation and it is a worthwhile experiment because, more than ever, we need primary care physicians to stay engaged as we work through our health care transformation. I argue that Medscape’s chart on ”average” physician compensation highlights the broader dilemma – namely that primary care (the very entry point for health care) is the lowest paid.

We pay primary care in much the same way that we pay tellers at the bank. Tellers aren’t dead – nor is their survival at risk – but it’s tilting heavily toward the retail economy. So are primary care physicians. These are all the ”gatekeepers.” In fact, that may well be the exact path we’re on as we attempt to automate (and further minimize) the dynamics of primary care. Several companies (eg: Healthspot – which I wrote about in my CES coverage earlier this month) are building the physical Kiosk’s specifically targeting low-acuity, primary care. As a primary care physician – the assault is relentless – from every direction.

  • Current payment rates that are unsustainable to a practice
  • Further cuts to payment rates in the forecast
  • Increasing demand for “accountability” (both regulatory and ACO’s)
  • Complete subjugation by other specialties – where primary care is treated as the “funnel” or “filter” to higher-rate specialties
  • Kiosk’s and eVisits as the final automation of primary care altogether (do we know who the doc-in-a-box is? Should we care?)
  • Ever increasing volume as more people join the ranks of the “insured”

The technology overlay is simply the gamification and behavioral economics to support an increasingly desperate need for lower cost, but it’s unrelated to any metrics that support either better health outcomes or better care delivery. We don’t know. It’s entirely experimental.

All of which speaks to the huge need for more systemic changes around payment reform. As it stands today, the Affordable Care Act (ACA) does little more than tweak the current payment model. Yes, Accountable Care Organizations (a by-product of the ACA) are scaling broadly, but adding a risk component to the payment of care doesn’t fundamentally change the “fee-for-service” model – or mentality. As Paul Levy highlighted, ACO’s are “Neither Accountable nor Caring nor Organized”. Ouch. Yes, provider compensation will absolutely be tied to outcome (including things like “re-admissions”), but is that really the biggest, the best and only lever?

Don Berwick has suggested three ”triple aims.” We all know the first – better care, better health and lower cost, which is the ultimate goal, but there are two others. The second is:

  1. We can get to better care, better health and lower cost – but we’re going to have to improve our way there.
  2. The 1st Law of Improvement is that every system is perfectly designed to achieve the results it gets (ie: the current system is performing as built).
  3. Improvement science is a system science – not an economic science.

The third is that there are 3 types of product improvements (and we need all 3):

  1. Defect removal (ie: reducing hospital infections, fraud and waste)
  2. Reducing costs (while leaving the customer the same or better)
  3. Creating a new product or service (ie: a new model)

Don’s preferred example of a new model is the (Malcolm Baldridge National Quality Award winning) Nuka system in Alaska– but it’s not the only example. I wrote about the success of “worksite healthcare” last year. Using back-of-the envelope math – SAS (#2 for 2013 – and on the list of Top 100 Companies to Work for – 10 times) estimates that they save about $6M per year on healthcare costs. It’s not just lower cost either. They continuously demonstrate much happier, more productive employees – who also enjoy better health.

When describing either model, Nuka or worksite, there is almost no reference to digitized workflow. There is no reference to “gamification” or ”behavioral economics.” There’s also no reference to ”payment risk” or EMR “woes.” There is just improved healthcare – and the result is threefold. Better care, better health and lower cost. Triple aim. It does exist – and there’s even more than one model. We can get there but it’s through improvement. As Don Berwick suggests – that’s a system science – not an economic one. Unless and until we see that – I question how much healthcare transformation we’re actually getting. I’m just asking.

Dan’s right – it is not just about the data and coding. There are no quick fixes but listening to the clinicians and individuals enduring some of these changes is a good starting point and his point about primary care physicians is important – the key to helping patients manage their care. I would suggest that perhaps that what will happen is individuals will take on more of this role, supported by technology and clinical professionals (and not just doctors)

Restyling the Mundane Medical Record Could Improve Health Care

Posted in Clinical Documentation, EHR, EMR, HealthIT by drnic on January 18, 2013
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Too good to not follow up to the previous post as another great article on re-workign the medical record (perhaps medical “record” is not a great term?). Personal Health Story/Personal Health History/Personal Health Chronicle…
Whatever we call it this will be is the way our health information will be stored and shared