Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
Time is money, an adage the world follows. When providers realized paper medical records were time-consuming, Electronic Health Records were developed to make things streamlined. Early EHRs were only meant to capture basic clinical information, and over the time EHRs have taken the form of a digital version of paper medical records. In an industry as dynamic and as focused on value as healthcare, it’s not feasible to have physicians spend almost half their time on EHRs.
Challenges physicians face with EHRs
EHRs, in their current state, not only consume a lot of physicians’ time, but they also draw their attention away from their direct interactions with patients. Some of the several significant challenges physicians face are:
Data entry and administrative tasks take up a lot of physicians’ time, according to a study, during the office day, physicians spend as much as 49.2 percent of their time on EHRs.
The demands of desk work and administrative work are not being reconciled with patient priorities and clinical workflows; creating huge gaps between patients and providers. For example, during patient examinations, physicians spend 37 percent of their time on data entry and desk work, compromising on their direct interaction with patients.
Physicians are only reimbursed for face-to-face visits, lab work, and medical procedures and not for EHR tasks. This increases the misalignment in fee-for-service payments and compounds the risk of physician burnout.
Why can’t we do away with EHRs?
While EHRs are not without their own set of challenges, their implementation was necessary, and that still holds true. Only recently, under the Merit-Based Incentive Payment System (MIPS), providers have started to make an effort to enhance value in the care they deliver and the meaningful use of EHRs has been included in MIPS with other substantial quality reporting initiatives. Besides that, there are many offerings of EHRs:
A quick and real-time access to patient records.
Reliable drugs and test prescriptions.
Complete clinical documentation, inclusive of patient medical history.
Accurate and streamlined coding and billing operations.
Reduced cost of operation.
EHR Optimization: Boosting your EHRs
EHR optimization is the process of enhancing and refining the operations of an already installed EHR, to enhance clinical productivity and efficiency. As more and more practices have begun the push for value-based reimbursement, they are demanding more integrated and efficient EHRs.
Opportunities for EHR optimization vary for every practice and range from simple to complex. However, the primary objective of every optimization is reducing the time consumed. Here are some ways healthcare IT platforms can optimize time spent on EHRs for improved patient outcomes:
Establish key performance indicators: Once a healthcare organization has examined its baseline performance, it can decide on goals and target a benchmark for future. Organizations can leverage advanced analytics to determine their progress across each key performance indicator which in turn, helps with quality reporting.
Comprehensive and complete clinical records: It’s important that a patient record is complete- right from their past medical history to their last lab test results. Along with that, if providers are able to look at all vital signs at once, the entire process of designing and implementing a care plan would become efficient.
Implementing clinical decision support: By combining clinical decision support with EHR data, providers can ensure safer and efficient care delivery by documenting every interaction and eliminating redundancies. With every information documented, providers can address the gaps in care well in time.
Sharing vital information across the network: More often than not, the delay in accessing information is the major reason behind improper or delayed care. It’s important that clinical data, lab test results, referrals, etc. are shared across all providers to ensure seamless treatment and population health management.
Monitor, evaluate and maintain results: To ensure the success of optimization isn’t short-lived, providers should continuously monitor their process improvement. Organizations should evaluate their growth and shortfalls and make their efforts to sustain and improve the results they achieve.
Guest post by Matthew Douglass, co-founder, SVP Customer Experience, Practice Fusion
In part 1 of this series, we reviewed the history of digital health tools and discussed why they are not yet fully satisfying the needs of many physicians.
If you think of the U.S. healthcare system as a vast nationwide transportation network, current electronic health record (EHR) functionality is the basic highway infrastructure. The American Recovery and Reinvestment Act of 2009 provided the incentives for those highways to be built and put in place the structure for ONC-certified EHRs to define the rules of the road via regulatory standards. The roads are now mostly in place: certified EHRs all offer roughly the same base functionality for use by physicians, store clinical information in standardized ways, and have the capabilities to securely communicate with each other.
Sixty-seven percent of medical practices in the U.S. are now using EHRs to run all or part of their daily operations. Patients’ vital signs are stored as discrete values for each visit. Encrypted messages between physicians and their staff are transmitted reliably. Chart notes are being digitally documented and can be shared confidentially with patients. Physicians that have chosen cloud-based EHRs can securely prescribe and refill medications from the convenience of their mobile phones.
Despite having this digital highway system in place, we haven’t yet reached a destination where use of EHRs achieves better patient outcomes or improved clinical experiences. Physicians want more from digital tools than simply receiving, storing, and displaying data values about each patient visit. Rather than devoting too much of their already limited time to data entry and retrieval, physicians want to provide the best patient care possible, and they expect technology to help them achieve this goal.
There is such a thing as too much data, which physicians are reminded of each time they open a digital chart. Clinicians very often are left swimming in more data than they can adequately process, which can erode the crucial patient-provider human relationship.
To address data overload and dehumanization challenges, software partners must go back to the drawing board and visualize dramatic innovations that can be built on top of the nationwide EHR foundation. Significant cognitive overhead is required to distill hundreds of disparate pieces of clinical data into a salient picture of an individual’s overall health. The vast amount of data now available in a patient’s chart is quite often far more than any medical professional, no matter how clinically experienced, can consistently and reliably assimilate.
Physicians and their staff need intuitive technology to be their always-available, intelligent assistant, from start to finish during a patient’s visit.
When a patient’s record is displayed on the computer screen, physicians shouldn’t have to dig for relevant information about that visit. Instead, the EHR should be able to display the pertinent clinical data and health insights for the physician to review and assess a patient’s health condition more quickly and effectively. For example, lab values and vital signs relevant to that patient’s chief complaint are likely already stored as discrete values in the patient’s chart. An EHR that learns along with the physician’s workflow preferences should display only the most relevant data through easily digestible visualizations.
Guest post by Matthew Douglass, co-founder and SVP of Customer Experience, Practice Fusion.
Despite enjoying broad technological advances in their medical practices over the past decade, many physicians still find little pleasure in having to use electronic health records (EHRs). Reasons for low satisfaction run the gamut, from a litany of potentially distracting alerts to overwhelming features that are difficult to learn. This flagging usability, combined with the growing burden of data entry and documentation, impedes physician satisfaction.
Physicians do not begin their careers in medicine so they can spend a majority of their time wrestling with technology. A recent study found that physicians spend three times as many hours working on computers as they do providing direct patient care. It is no wonder that physicians are reporting record levels of burnout and deep job dissatisfaction.
There are practical workarounds to the challenges of using EHRs, such as programs pairing physicians with scribes that are pre-med students who assist those physicians or plugging in additional technologies that reduce direct documentation overhead. However, these practical workarounds mask the root problem rather than address it; EHRs have yet to provide consistently actionable insights that will help to dramatically improve clinical outcomes.
When a physician opens a patient record in her EHR today, she is probably no better equipped than if she were to open that patient’s paper record 10 years ago. All the data points she might ever need are available for her to sift through, but where is the insight? How is she supposed to interpret clinical meaning in individual pieces of data scattered throughout her patient’s history? How is the EHR assisting her in making better, more informed care and treatment decisions for her patients’ lives that she has been entrusted with improving?
EHRs were originally created as a digital recreation of the physical paper chart that accompanied a physician into the exam room during every patient visit. Vital sign collection sheets were recreated as vital sign fields on the screen. SOAP notes that physicians judiciously completed with pen and paper after every patient visit became digital SOAP note fields in the EHR that still have to be typed by the physician or a physician’s representative at the end of every patient visit. Billing one-pagers with pre-printed ICD and procedure codes have been replaced with nearly identical digital superbills containing point-and-click picklists of diagnoses and procedures.
Although we have created a digital system, the healthcare industry lingers in an analog world: Everything still operates like paper.
In the early 20th century, Henry Ford envisioned a future where transportation was dramatically better than what the main transportation technology of the time (i.e., horses) could provide. Confronted with this problem, he didn’t try to re-engineer horses to run 10 times faster. Thankfully, he set his sights on an entirely different and improved solution, experimented with a few ideas, and succeeded in completely altering the future of human transportation by introducing the first mass-produced automobile.
EHR vendors have a similar opportunity today, as they imagine the future of digital health technology that will be highly usable and incredibly helpful for physicians. Fortunately, EHRs are now broadly distributed enough that there is a solid foundation in place on which to build . Now that the vast majority of patient clinical information lives in a digitized form, we can look to the future and ask a novel, crucial question: How can this rich repository of clinical data evolve into upgraded tools that can be used to broadly improve patient health and physician satisfaction?
To best answer these questions, EHR vendors need to reevaluate the specific assistance that physicians can garner from digital health tools. First, clinicians and their staff must be intimately involved in the functionality discovery process in partnership with EHR vendors. This research can then be converted into success metrics and key questions that clinicians and vendors’ product teams utilize as benchmarks for measuring overall successful implementation.
Am I happier as a clinician because of this functionality?
Am I able to devote more or less time to focusing on my patient because of this functionality?
Overall, did this functionality save or cost my practice time and money?
Are my patients healthier and more satisfied with the service my practice provides them?
Further, as physicians are evaluating which digital health technology vendors to partner with in their practice, there are a few advantageous traits they should consider. EHR vendors that operate in a secure cloud offer distinct advantages because they can roll out frequent updates that do not interfere with a practice’s day-to-day operations. If a bug or usability issue does arise, the problem most often can be addressed quickly and without interruption.
We put a lot of faith in health technology: to make us better, to save our systems, to revolutionize healthcare. We may be looking at it from the wrong side entirely.
The social determinants of health matter more than our ability to deploy doctors or provide insurance; physical and mental, health is always more social than clinical.
But most of our health tech that is supposed to be revolutionary is aimed at clinical factors, rather than the social determinants of health. Yes, telehealth can increase reach, but it is still just a matter of touchpoints, not a fundamental change to the lifestyles and cultures that determine health.
Same with all our EHR systems creating more ways to record information, more ways to quantify patients, to put more emphasis on engagement and quality-based reimbursement. Even genomics and personalized medicine are taking a backseat to soliciting reviews and trying to turn the patient experience into a number. It all puts greater focus on the clinical encounters, on how patients “feel” broadly about each minute aspect of their time in the medical facility.
A Digital Disease
As politicians trade blows on minimum wages and the ACA, the likelihood grows that insurance benefits and livable incomes (and lifestyles) will get pushed further out of reach for more people.
Modern work is tech-centric, which means lots of sitting, and manages to facilitate increased snacking without being particularly physical, a double-whammy that prevents employment or higher incomes from leading to healthier choices. For the less-skilled, normally accessible jobs are in the sights of automation and disruption. While tech is taking over medicine and opening up new possibilities, it is also transforming the labor market and closing countless doors to workers.
By extension, technology is changing the social framework that determines public health. Income inequality is growing, wage growth is stagnant, and no amount of awareness can change these front-of-mind concerns for people who may well want to eat better and exercise more, or even commit to seeing the doctor more often and following his or her advice to the letter.
Poor people can’t necessarily eat better as a simple matter of choice or doctor’s orders. Planning meals and purchasing healthful foods is a tax on limited resources–time as well as money. Working three jobs to pay the bills, many lower income individuals also don’t necessarily have time to exercise. And more likely than not, those working even high-paying jobs are sitting all day, sapping their bodies of energy and resilience, undoing the good of their intentions and smart devices alike through attrition.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
The US healthcare is getting costlier every day, and it is without a doubt true that most of the US citizens live in fear that they won’t get access to the care when the illness strikes. The sad truth is that every year more than 100,000 deaths occur because of medical errors. All this when we see horrifying figures even after adjusting the America’s higher per capita GDP; US spends roughly $500 billion more than other developed countries.
The Problems with Coordination
13 years ago, way back in 2003, the Institute of Medicine had identified the most persistent problem in the healthcare industry, and it was coordination. The idea behind implementing EHRs was to create digital data that is easy to share, but that did not happen. According to a study, 63 percent of primary care physicians and 35 percent specialist are not satisfied with the information they receive from other physicians within the adult referral system.
The above graph shows how poorly coordinated care has affected the adults. The US stands second when it comes to high-need patients. This is when US spends more than $10,000 on one person’s health.
According to a research article, the biggest challenges Primary Care Physicians and Hospitalists faced were:
Difficulty reaching out other clinicians
Lack of information feedback loops
Lack of general information like clarity on test results, history, and medications, etc.
Insufficient access to discharge information of patients
Working towards a solution
Besides these, a lot of problems arise when patients miss out on medications, follow-up visits or any other requirements. Thus, there is a need to create a process where neither do PCPs miss out on critical information nor does the patient stay unaware of the care plans. For this PCPs had identified the most successful care coordination components:
Better coordinated care for at-risk patients
Enhanced direct contact with patients through phone calls
Advanced use of EHRs for better health information exchange
Developing better interpersonal relationships
Health coaches connecting care
The most important aspect of healthcare is that when a care process is nearing its end, the patient should be in a better state. A patient-centric approach is must to make sure a patient gets the best treatment. Health Coaches ensure that the patients get what they need. They make sure that the
Patient doesn’t miss out on his medications
Patient attends follow-up visits,
Patient has no transportation barrier while visiting a hospital
Inform family/caregiver about the care plans and the patient
Track and make sure adherence of care plans
Review discharge instructions
The Three Pieces of Care Coordination
More often than not care coordinators miss out on the essential information about the patients. In worst cases, they have no discharge information of patients creating gaps in care and indirectly increases the cost of care. Ideally, the three pieces of care coordination together can bring dramatic improvements in patient-centric care. The three pieces are:
When we talk about technology disrupting healthcare, we aren’t just referring to changes in the accuracy of health records or the convenience of mobile care; the real disruption comes in the form of fundamental challenges to traditional scopes of practice.
What Should We Do?
Scope of practice, broadly, is determined by a combination of liability and capability. Lead physicians carry greater liability than the bedside nurses assisting in patient care, because the care plan is directed by the lead physician. Likewise, the extra years of education and practice are assumed to increase the capacity of physicians to lead their care teams, make decisions about how the team will go about its work, and parse all of the information provided by the patient, nurses, and other specialists involved with each case.
In every other industry, productivity increases come from technology enhancing the ability of individuals and teams to perform work. Email saves time and money by improving communication; industrial robotics standardize manufacturing and raise the scale and quality of output. Every device, app, and system allows individuals to scale their contribution, to do more and add more value. Word processing and voice-to-text enable executives to do work that might otherwise have been performed by a secretary or typist. Travel websites allow consumers to find cheap tickets and travel packages that would previously have required a travel agent to acquire.
In healthcare, technology is changing the capacity of the individual caregiver, expanding what can be done, and often how well it can be done. These improvements, along with a growing need for healthcare professionals and services, are challenging traditional notions of scope of practice–for good and bad.
Some of the changes to scope of practice are positive, necessary, and constructive. For example, technological literacy is necessary at every point in the care continuum, because interoperable EHRs and the vulnerability of digital information means that everyone must contribute to cyber security. In a sense, caregivers at every level must expand their scope of practice to incorporate an awareness of privacy, security, and data management considerations.
By extension, all caregivers are participating as never before in the advancement of clinical research, population health monitoring, and patient empowerment simply by working more closely with digital data and computers. As EHR technology iterates its way toward fulfilling its potential, caregivers and administrators are being forced to have difficult conversations about priorities, values, goals, and the nature of the relationship between patient, provider, system, and technology. It is overdue, and foundational to the future of healthcare.
Is There A Nurse in the House?
The trend in healthcare toward prevention and balancing patient-centered care with awareness of population health issues puts primary care in a place of greater importance than ever. This, in turn, is driving a shift in the education of nurses to promote more training, higher levels of certification, and greater specialization to justify relying on nurses to fulfill more primary care roles. They are becoming better generalists and specialists, capable of bolstering teams as well as leading them.
The advancement of diagnostic technologies and understanding of the nature of disease, illness, and genetics has also thrust the clinical laboratory into the center of healthcare. It doesn’t necessarily change the scope of practice for the laboratory scientist, but does elevate the demand and scale of operations for these professionals must fulfill. Once again, the broadening demand has dovetailed with an effort to broaden the scope of practice for other clinical roles, particularly nurses.
Whether it is appropriate or practical for nurses–already understaffed and overextended–into all these critical blended roles is open for debate.
Man, Machine and Medicine
While cross-training is valuable for improving collaboration and breaking down siloes–both critically important to the future of healthcare–it blurring the scope of practice or between roles that comprise very different skills and responsibilities. Technology is expanding the capability of every clinical and non-clinical role, but is it not entirely clear whether it is keeping up with our expectations and demand for the people in these roles.
In addition to answering these questions about scope of practice, we need to look carefully at how technology can change the scope of accountability for patients. Technology may be a platform for engagement, but getting real patient participation requires a better foundation of health literacy–just as caregivers must develop a more robust technological literacy to take advantage of EHRs.
In virtually every context that question might be asked, we struggle to give an honest, accurate answer.
It Works If You Believe It Works
Is the medication working? Difficult to say–it may be the placebo effect, it may be counteracted by other medications, or we may be monitoring the wrong indicators to recognize any effect. Is “working” the same as “having an effect,” or must it be the desired effect?
Alternative medicine confounds the balance of expectations and outcomes even further. Right at the intersection of evidenced-based medicine and naturopathy, for instance, we have hyperbaric oxygen therapy, or HBOT. These devices are as much in vogue among emergency departments (to treat embolisms, diabetic foot ulcers, and burns) as holistic dream salesmen (to prevent aging and cure autism, if you believe the hype). When the metric being tracked is as fluid as the visible effects of aging, answering whether the treatment is working is about as subjective as you can get.
As though the science of pharmaceuticals and clinical medicine weren’t confounding enough, you can hardly go anywhere in healthcare today without politics getting added to the mix. In the wake of Trump’s victory in the 2016 presidential election, you have observers and stakeholders asking of the Affordable Care Act (ACA): is it working?
There’s Something Happening Here
It is definitely doing something. It is measurably active in our tax policy, for instance: 2016 returns are heavily influenced by the incremental growth of the ACA’s financial provisions. Of course, the point of this tax policy (depending on who you ask) is to influence behavior. As to this point, there are some signs that, again, something is happening: among young people, ER visits in general are down, while emergency stays due to mental health illness are up. We changed how healthcare is insured, and that changed, in turn, how we access our care. But is it working?
Advances in technology have fundamentally altered and inarguably improved the way we drive, shop and travel. Just ask anybody who uses Google Maps, Foodler or Uber.
Sadly, however, information technology has failed to deliver so far in the most crucial service of all – healthcare. This is at least partly because electronic health records (EHR) systems grew out of the computer systems that run the hospital’s inner workings — patient scheduling, admission and discharge, staff payroll and accounts receivable. For system designers, physicians’ needs were an afterthought, which is problematic because physicians are, after all, the linchpin of the healthcare delivery system.
To begin pulling healthcare IT out of the past, we must first take a look at how it supports physicians. The short answer today is “not well.” In fact, EHRs are creating as much frustration as benefit. Problems include poor presentation of patient data, fragmented information sources and unwieldy user interfaces that require dozens of mouse clicks or screen taps. It’s no wonder more than half of physicians who responded to a recent survey claimed their EHR system had negative impacts on costs, efficiency and productivity – three things IT should help, not hinder. These issues not only affect physicians’ professional satisfaction, they contribute to the phenomenon of physician burnout, which is a growing concern across healthcare. Studies show some 30 percent of primary-care physicians age 35 to 49 plan to leave medicine, and there’s an expected shortage of 25,000 surgeons by 2025. A Mayo Clinic study released earlier this year directly connected the burnout problem to physicians’ use of EHRs.
Today’s EHRs have done little more than “pave the cow paths.” We’ve gotten rid of paper in the hospital and made processes electronic, which is why EHRs can legitimately claim to have reduced transcription errors. But eliminating paper is just table stakes; the critical next phase is to do for healthcare what Uber has done for transportation: Reinvent the process so it’s optimized for and native to the technology that enables it.
Patients and physicians can and should advocate for such change. Today, patients have access to a vast body of information—the notes a doctor took, quality of care rankings, the level of personalization provided—and it’s only going to increase. As Lygeia Ricciardi, former director of the Office of Consumer eHealth at ONC said, “Getting access to personal health information is the start of engaging patients to be full partners in their care.”
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
The digitization of healthcare was a much-needed change brought after years of hard work and effort. One might wonder how could one justify the expenditure of $10 billion in a span of five years just on digitization. The problem intensifies when after several studies we find out that EHRs only reciprocate around 30 to 35 cents on a dollar and sometimes the figure dips to 15 cents.
Why have we digitized healthcare when the efforts required to get the desired result is still too much? I think we haven’t used the available technological aids appropriately. It is like driving a car at midnight and not knowing that you have headlights. You can have a clear view of your path, you can get to your destination fairly fast but can’t because you don’t know what is going to help you and in what way, your performance is reduced to a great extent to be able to achieve what you desire
Justified use of EHR could create the needed ecosystem
According to a report, 10 percent to 20 percent of savings are possible if a value-focused healthcare organizations capitalize on EHRs and interact with their patients better through technology. The amount that could be saved annually per bed is in between $10,000 and $20,000.
There are incentives for meaningful use of EHRs, but the truth is that the return through meaningful use incentives is somewhere around 15 or 20 cents on a dollars. There have been implementation, stabilization and optimization problems that have made it hard for healthcare organizations to extract the best out of EHRs. Practices will have to start using data as a source of innovation and come up with solutions that’ll not provide them better incentives but assist them in providing even better patient-centric care.
There are certain key points one can work on to make their healthcare ecosystem more efficient and patient-centric. Only judicious data usage from data disparate sources can help in so many ways, imagine what else is possible with advanced solutions. The integration of EHR with different disparate sources could be really beneficial in understanding the factors that drive value-based care. For instance, with the help of various data one can perform:
Population Health Management: With the help of data collected from different sources, impact at a population could be created and analyzed. Once you have the data of millions of patients, imagine all the things that are possible. Identification of at-risk patients, stratification of patients on the basis of various disease registries, better decision making, and a lot more. According to a study, due to disease management programs the cost of care were reduced by $136 per member per month because of reduction in admission rates by 29 percent.
Variations in Care Delivery: Efficient analytics and data management can help answer many questions. The medication process could be streamlined on the basis of past cases, and identified opportunities could be capitalized. Also, a thorough data-driven analytics could provide substantial insights on the performance of various facilities and how they differ when it comes to care delivery process.
In the age of the digital hospital and the connected patient, security will likely improve the less it depends on providers.
Everything from HIPAA to patient engagement treats physicians as the white hot sun of the healthcare universe, holding everything together and keeping it all in stable orbit. They are accountable for health outcomes, for patient satisfaction, for guiding patients to online portals, and for coordinating with care teams to keep data secure — even as mobility and EHR dominance complicates every node in the connectivity chain. All this digital chaos brings more diminished security.
Only as Strong as the Weakest Link
Every business out there has learned — usually the hard way, or by watching someone else learn the hard way — that whatever the security infrastructure, users are the weakest link. More devices means more users, and more connectivity and data-sharing means more weak spots all along the chain. By design, the EHR system adds vulnerability to healthcare data security through a long chain of users.
Patients don’t have a systemic, accountable role in all of this. Our whole approach fosters passivity on the part of the patient and paternalistic assumptions on the parts of caregivers and policymakers. We give tacit acknowledgement of this imbalance whenever malpractice law or tort reform is mentioned — and promptly left behind in the face of other, patient-exculpatory programs and initiatives.
Patients are a part of this. Clearly they are invested in their own security — the costs of health data breaches contribute to the rising costs of care, besides exposing personal financial and medical information that can carry its own universe of costs.
Patients are implicated, but they must also be accountable for security in the new high tech healthcare system.
An Old Problem with New Importance
Getting patients included in the evolution and delivery of healthcare requires engagement. The same goes for digital security. The ethical and financial dilemmas of the security situation is an expensive distraction for administrators and caregivers, but it is a learning opportunity that could empower patients. A new emphasis on digital security and privacy could be the start of a cascade of engagement with further questions of use and responsibility for outcomes.
Already, patients are key players in making telemedicine effective. Access is on the shoulders of the patients, and utilization depends on their technical literacy. The incentives–time and money savings, improved access to care–are powerful, but come with the obligation to learn the platform through which remote care is delivered. Utilizing any telehealth solutions requires patients to think about what information they want to share, whether they trust the new platform, communicating effectively with their provider, and gaining confidence for the new medium.
This same model can be applied more broadly to EHRs, and the patient role in the digital healthcare system.