Healthcare Technology need to include Patients

A survey conducted at HIMSS15 found that patient satisfaction

and patient engagement rank among the top priorities for CIOs. In fact, they rank above improving care coordination, streamlining operational efficiencies, and achieving Meaningful Use.
The tides are clearly changing. We’ve all been talking about what the shift to a value-based care model means for healthcare organizations. What we haven’t been talking about is how this shift is transforming our patients into “prosumers.”
There’s a saying, “To a worm in horseradish, the world is horseradish,”

meaning we are predominantly aware of that which we are surrounded by on a daily basis. Health IT, in all its intricacies and expansiveness, has become hyper focused on making sense of its nebulous infrastructures, working hard to prepare healthcare organizations for next new wave of regulations. Our world, while not horseradish, is composed of goals and milestones that are 100 percent contingent upon these systems.
But, as yet one more unintended consequence of this pursuit, we have become myopic. The business of healthcare is no longer simply confined to a hospital or an IDN site map.
Patients are reaching for their phones, not to call their doctors, but to research their symptoms. They’re educated buyers, looking up reviews before seeing a new specialist, just as they would before buying the latest gadget on Amazon. And, as we enter the era of the Internet of Everything (IoE), they want their wearable devices to meaningfully connect as simply as when they use their phones to play songs from the playlist on their laptop.
It becomes a challenge of sustaining the momentum of the moment. As the wearable trend continues to grow, it is not merely enough to count steps or measure the amount of UV rays absorbed. That won’t keep patients engaged. We need statistics and personal health trends that can be used to foster a richer, ongoing dialogue between patients and their physicians.
Consider the positive health implications for patient who receives a treatment plan from her doctor, which is entered into the EMR during the visit and connected to a three-question daily check-in for three months via a mobile device. The patient could provide a thumbs-up, thumbs-down, or neutral rating (think Pandora playlist) on how the treatment is working, with perhaps an option to enter free text should she choose to expound upon her responses. These daily reports could be aggregated into trends and reviewed by a clinician to make adjustments to the treatment plan as needed, extending patient care beyond confines of the four walls and the 12 minutes of an office visit.
Connectivity and personalization is the zeitgeist. CIOs know this. We are all unique snowflakes, and as more and more people submit their genes for analysis and mapping, we’re proving the increased drive for individuality. While the industry is pushing for population health (a laudable vision indeed), patients are looking not to be considered in aggregate, but to be treated with the same personalized attention they experience when they go to a favorite restaurant where the wait staff recalls their usual order or when they go to a website that remembers all their previous preferences. It’s about not starting from square one every time.
Patients aren’t going to tolerate the disconnect in healthcare forever. And as digital natives,some generations won’t tolerate it at all. The day is coming where a patient will ask her doctor, “Did you notice that that my headaches seemed to lessen on those days I go to the gym? I’m wondering if there’s a connection?” If her physician isn’t paying attention to her, she will find a physician, or perhaps even an intelligent medical assistant, who will.


This post originally featured on HISTalk

Physician Symposium #DrHIT #HIMSS14

The Physician (#DrHIT) Symposium at #HIMSS14
Opening session was eloquently covered by Robert Wah, MD (@RobertWahMD) detailing the spectrum of issues ranging from the new Healthcare System:

The challenge of SGR “fix(es)” and the evolution of the systems we are implementing and the value proposition. As he put it

Quality of care is improved with better information — saving lives and money

But Health Technology is not easy to implement:

Health tech is hard, but harder part is changing #workflow & #workforce. @RobertWahMD#HIMSS14#DrHIT Org alignment: pic.twitter.com/AQsX1a3846

— Wen Dombrowski MD (@HealthcareWen) February 23, 2014

And layered on top is the increasing challenge of securing the data with hackers seeing healthcare data as 15x more valuable than financial hacked data!

MT @CraigJoseph: #DrHIT@RobertWahMD Arms race btwn those trying to protect patient data & those trying to get it. Who'll win? #HIMSS14

— HIMSS (@HIMSS) February 23, 2014

What we need is coordinated care and Dr Wah offered this visual of the way forward

Christine Bechtel focused on the Activate Evidence Based Patient Engagement and as she reported - Patients like doctors who have an EHR

Patients think EHRs help doctors deliver better care

• Timely access to information, sharing info across care team, med history, managing health conditions
• Overall, EHRs were rated between 23%-37% points higher than paper on these elements

Interesting since doctors have been reported as saying they dislike the EHR but patients like seeing their doctors with an EHR

MT @drnic1: 80% patients say online #EHR access improves #health and a reason to stay with a practice. #DrHIT#Himss14#HITworks

— HIMSS (@HIMSS) February 23, 2014

The sad thing was this session was concurrent with @ePatientDave in another room - The Connected Patient: Learning How Patients Can Help in Healthcare only social media united these sessions

@cmaer@ePatientDave Missed opportunity - would be so much better to have those two intersecting rather than in parallel #DrHit#HIMSS14

— Susan Shaw (@drsusanshaw) February 23, 2014

As for Jonathan Teich and his session Improving Outcomes with CDS - he used his personal experience where peer pressure (as he described it 3rd time he was pressured to take on an expert triple diamond ski slope) he finally agreed and ended up in a serious ski accident fracturing multiple vertebrae. Interesting analogy relative to the Clinical Decision Support System and the pressure this applies to clinical practice sometimes inappropriately...
Interesting look at alerts and the potential for providing more than just alerts but actually providing intelligent data that distill down to 10 types of CDS interactions

1. Immediate Alerts: warnings and critiques
2. Event-driven alerts and reminders
3. Order Sets, Care Plans and Protocols
4. Parameter Guidance
5. Smart Documentation Forms Improving Outcomes with Clinical Decision Support: An Implementer’s Guide (HIMSS, Second edition, 2011)
6. Relevant Data Summaries (Single-patient)
7. Multi-patient Monitors and Dashboards
8. Predictive and Retrospective Analytics
9. Filtered Reference Information and Knowledge Resources
10. Expert Workup Advisors

And the important summary slide was the CDS Five Rights (Right information, people, formats, channels and times)

And returned to one of the core opportunities - Patient Engagement with a a session by Henry Feldman, MD FACP: Informatics Enabling Patient Transparency. He asked the same questions as another presenter - how many fo the audience considered themselves a patient (Still only a shabby 80%) and then took this further asking

• You feel that you know exactly what your provider was thinking in making his decisions
• You think the clinical systems helped your provider understand comprehensively everything about you
• You build clinical systems or are a provider
• With the inevitable decline in hands up
• You think your (or anyone else’s) software truly helps the patient or even the provider understand comprehensively or transparently what is going on

Sadly we are not near this and the reality is much further with physicians thinking patients are unsophisticated. Yes at he pointed out the airline industry gets it and even the DMV/MVA gets it offering customer engagement models:
Their experience and stats blow the unfounded resistance out of the water

• Only 2% of patients found notes more confusing than helpful
• Only 2% found the note content offensive
• 92% said they take better care of themselves
• 87% were better prepared for visits

Importantly we need to turn data into information for patients and he cited the Wired example of a Laboratory test (Blood Test Gets a Makeover Steve Leckart) and the makeover for
Basic Labs

Cardiology Result

and the PSA result

I know where I'd like to be receiving my care (and lab results) from! Great finish to the session. So as he summarized where we should be with patient engagement an data

• Open your data to your patients
• Patients understand more than we think
• Teach patients how to use data effectively – This can save you time in the long run
• Put your patients to work on their own health!
• Vendor work on how patients will view big data
• It’s a new drug, research the risks and benefits

Great start to what will be a busy HIMSS

Integrating Clinical Documentation Improvement into the Doctors Workflow

We know doctors are under an ever increasing load may eventually break their backs..if nothing else its increasing the overall pain

In a recent study of physician attitudes toward clinical documentation technology and processes clinicians the majority of clinicians said they would be more responsive to Clinical Documentation Improvement (CDI) clarifications if they were delivered in real-time within their normal documentation workflow in the electronic health record (EHR). They report being "disrupted" by queries for additional information

after they’ve documented in a patient chart or worse, after the patient is discharged.  All believe that ICD-10 will make matters much worse

With #HealthIT a growing portion of how doctors do their jobs they want to be involved in technology decisions yet most were not involved in clinical documentation technology decisions for their organization. And timing is everything - going back to answer questions after you have left the patient or worse after the patient has left "the building".


So what is the difference between success and failure of a CDI program

As the study points out physicians’ growing dissatisfaction in being

saddled with processes that distract them from clinical care, while being excluded from the decision-making process of choosing things that impact them every day

Technology should be simple and work for physicians and the key to changing the experience is to eliminate rework

Rework in clinical documentation is the enemy of efficiency

As Brian Yeaman, MD CMIO for Norman Regional Health System puts it

Using things like CLU and applying that to the ICD-10 code book to help me refine that diagnosis or ask me whether it’s the left or right or an upper or lower extremity are tremendous because it has a significant impact on our bottom line, and it’s also a physician satisfier … and on the back side we are not getting so many coding queries

And Reid Conant, MD President and CEO of Conant and Associates says

“Now we can provide our physicians with tools to get real-time feedback to not only change that document, but also change their behavior for the next document. That’s what organizations are looking for, and frankly, that’s what the doctors are looking for.”

We can achieve ICD10 compliance without breaking the back of clinicians

Technology as an Aid vs Hinderance to Doctors

A recent article in Becker Hospital Review:  Technology Should Aid Human Interaction: Q&A with Dr. Nick Terheyden, CMIO of Nuance featured some important points to make

Health IT needs to fade into the background. It needs to become part of the fabric of the office rather than the focal point, and then the interaction will change

• Using the tools to allow the clinician to focus on the patient not the technology
• Human beings deal in narrative and stories, patients want to tell their story and clinicians need the richness of the narrative to help guide medical decision making
• Remove the Physical Barriers to the clinicians patient interaction
• Healthcare is not the focus - the patient is
  

The key to our future and to the successful use of health IT will be turning the focus back on patient and the physician.

What is Clinical Informatics

In a recent online discussion the question was posed "what makes up the skills and requirements of a CMIO". There was much discussion on the nature of the job, the skills needed and where new recruits needed to go to get those skills. But one reply stood out linking the skill set to everything we learn and do as clincinas. So with the permission of of a W Joseph Ketcherside MD, CEO of the Ketcherside Group and a Clinical informaticist who also practices of clinical medicine I post his response in it's entirety

Our patient (a health care system) comes to us with a Chief Complaint (I want to install an EMR).

We gather a little more specific information by taking a History of Present Illness (Why do you want to install an EMR? Improved safety? Decrease cost? Improve quality? Integrate inpatient and outpatient care? And so on.)

We take some Past Medical History (What systems have you worked with before? Any successful implementations? Failed ones?)

We do the ROS (How do you sit in the market? Market share? Referral areas and types? What are the financials? What is the culture overall?

What academic relationships do you have? What is your system's relationship to the community? And so on.)

Then, we do the Physical Exam (Current state analysis and documentation. Palpate the database. Auscultate the medical staff.)

We develop a Differential Diagnosis (Major processes that could be impacted and possible solutions.)

We work with the patient (health system) to determine what a good health outcome would be for them (Future state model).

We come to agreement on a treatment plan (Implementation roadmap and project plans) that will reach that future state.

Then we operate (implement) and, hopefully, are lucky enough to provide ongoing care (continued improvements).

So, I still practice medicine. When I was a neurosurgeon I cared for multi-system organisms (people).

As a clinical informaticist, my patients are multi-organism systems. But, they are still my patients.

And, sitting in the ED on a Saturday night of a CPOE go-live, I would observe that CPOE implementation is exactly like clipping an aneurysm - hours and hours of boredom randomly interspersed with moments of stark terror.

So that's my two cents on the practice of Applied Clinical Informatics.

This resonates with me and is close to the points I made in a guest posting over at Healthcare
IT Today "A Day in the Life of a CMIO. WHat's your experience - what makes a good healthcare informaticist?
"