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.
Guest post by Abhinav Shashank, CEO and c0-founder, Innovaccer.
Former US President Abraham Lincoln once said, “Give me six hours to chop down a tree and I’ll spend four hours sharpening the ax.” After having a look at the efficiency of the US healthcare system, one cannot help but notice the irony. A country spending $10,345 per person on healthcare shouldn’t be on the last spot of OECD rankings for life expectancy at birth!
A report from Commonwealth Fund points how massive is US healthcare budget. Various US governments have left no stone unturned in becoming the highest spender on healthcare, but have equally managed to see most of its money going down the drain!
Here are some highlights from the report:
The US is third when it comes to public spending on health care. The figure is $4,197 per capita, but it covers only 34 percent of its residents. On the other hand, the UK spends only $2,802 per capita and covers 100 percent of the population.
With $1,074, the US has the second highest private spending on healthcare.
In 2013, US allotted 17.1 percent of its GDP to healthcare, which was highest by any OECD country. In terms of money, this was almost 50 percent more than the country on the second spot.
In the year 2013, the number of practicing physicians in the US was 2.6 per 1000 persons, which is less than the OECD median (3.2).
The infant mortality rate in the US was also higher than other OECD nations.
Sixty-eight percent of the population above 65 in the US is suffering from two or more chronic conditions, which is again the highest among OECD nations.
The major cause of these problems is the lack of knowledge about the population trends. The strategies in place will vibrantly work with the law only if they are designed according to the needs of the people.
What is Population Health Management?
Population health management (PHM) might have been mentioned in ACA (2010), but the meaning of it is lost on many. I feel, the definition of population health, given by Richard J. Gilfillan, president and CEO of Trinity Health, is the most suitable one.
“Population health refers to addressing the health status of a defined population. A population can be defined in many different ways, including demographics, clinical diagnoses, geographic location, etc. Population health management is a clinical discipline that develops, implements and continually refines operational activities that improve the measures of health status for defined populations.”
The true realization of population health management (PHM) is to design a care delivery model that provides quality coordinated care in an efficient manner. Efforts in the right direction are being made, but the tools required for it are much more advanced and most providers lack the resources to own them.
If population health management is in place, technology can be leveraged to find out proactive solutions to acute episodes. Based on past episodes and outcomes, better decision could be made.
The concept of health coaches and care managers can actually be implemented. When a patient is being discharged, care managers can confirm the compliance of the health care plans. They can mitigate the possibility of readmission by keeping up with the needs and appointments of patients. Patients could be reminded about their medications. The linked health coaches could be intimated to further reduce the possibility of readmission.
Guest post by Ben Oster, product manager, AvePoint.
Balancing the strategic needs of a business with the user-friendliness of its systems is a daily struggle for IT pros in every industry. But for healthcare organizations, safeguarding the data living in these systems can be especially daunting. According to a study by the Ponemon Institute, healthcare is a minefield for various security hazards. Within the last two years, 89 percent of healthcare organizations experienced at least one data breach that resulted in the loss of patient data. As healthcare businesses and the patients they serve adopt a mobile-first approach, providers must strike a balance between innovation and risk to prevent patient data (and internal information) from falling into the wrong hands.
The use of mobile devices and apps certainly enhance patient-provider relationships, but these complex information systems present new concerns surrounding compliance, security, and privacy. As employees and patients increasingly adopt smartphones, tablets, and cloud-based software into their daily lives, healthcare leaders must prioritize users’ needs while mitigating security risks. Mastering this dynamic requires healthcare companies to balance mobility trends like BYOD and cloud computing with regulatory requirements like HIPAA.
To lower the risk of data breaches, healthcare organizations need to defend their systems by identifying, reporting on, and safeguarding sensitive data. Here are a few steps the healthcare industry can take to join the mobile revolution without compromising security:
Start with discovery – Traditionally, healthcare organizations have taken a “security through obscurity” approach to protecting data. In other words, relying on the ambiguity of the data in their systems to ward off malicious attacks and breaches. But as technology emerges that personalizes patients’ end-user experience – such as online patient portals and electronic medical records – the less obscure healthcare organizations’ data becomes. With patients and medical staff accessing this data through a range of devices and workflows, knowing precisely what content exists in a healthcare organization’s infrastructure is essential to security. That’s why discovery is the first step to safeguarding content. Healthcare IT teams should also roll out internal classification schemas to determine which user groups need access to this data. By categorizing content based on these factors, healthcare companies can lay the framework for a truly secure system.
Guest post by Adam Klass, chief technology officer, VigiLanz.
Here are some downright chilling patient safety statistics keeping healthcare leaders up at night: Each year more than one million hospital patients – that’s 136 per hour, every day – are affected by sepsis, and 280,000 die. In addition, 82 people in hospitals are affected every hour, every day, by hospital-acquired infections (HAI), and 217 experience a preventable Adverse Drug Event (ADE).
The good news is that an emerging category of technology known as enterprise intelligence resources (EIR) can empower clinicians to more quickly and effectively tackle these infections and ADEs – and even prevent them from occurring in the first place. By integrating and analyzing massive amounts of data generated by multiple sources, EIRs are not only able to identify at-risk patients, but also to tell frontline clinicians in real-time what is happening – and likely to happen – with their patients. Equally important, the EIRs fit seamlessly into clinicians’ workflows, generating only essential alerts.
Built on flexible, interoperable data architectures, EIR platforms extend the value of existing EMRs by integrating real-time clinical and business intelligence with predictive analytics to address sepsis, HAIs and ADEs as well as a wide range of other patient safety and public health risks such as deep vein thrombosis (DVT), venous thromboembolism (VTE), C. difficile (C.Diff), MRSA, surgery site infections, Ebola and MERS. Armed with EIR-provided actionable insights, clinicians can optimize appropriate interventions that improve patient outcomes, reduce patient safety risk and support quality initiatives.
Time is of the absolute essence in addressing patient safety risk, particularly in the case of sepsis. Research has shown that the earlier the intervention, the significantly lower the mortality and morbidity. EIRs can help significantly reduce sepsis risk by enabling clinicians to:
Identify at-risk patients earlier. Based on historical hospital data, an EIR can create a profile and scoring system to calculate a sepsis risk score for each patient, flagging those whose risk exceeds a pre-defined threshold.
Automatically track at-risk patients. The EIR closely monitors patients’ sepsis diagnostics and vital signs, and automatically updates their risk scores in the EMR.
Deliver appropriate alerts. The EIR notifies clinicians when interventions are required and continues to monitor patients so treatment can be adjusted according to defined protocols.
Implementing this approach has been shown to reduce sepsis occurrence by double digits. Most importantly, patients’ lives are saved. At the same time, reducing sepsis occurrence can also significantly reduce costs, given that sepsis accounts for 40 percent of ICU spending and nearly $29 billion in healthcare expenditures.
Have you ever sought medical care from multiple providers for the same condition? Then you probably already know how difficult it can be to coordinate care from one practice or facility to the next. One provider may not necessarily have access to the test results ordered by another provider, and even getting a prescription filled can be a hassle — you have to wait while the pharmacist fills your prescription and hope that he or she doesn’t misread the prescribing doctor’s terrible handwriting.
But all of that is changing; for many patients across the country, it has already changed, thanks to the Health Information Technology for Clinical Health (HITECH) Act of 2009. This law was enacted to encourage the transition to electronic health records (EHRs) in medical practices, hospitals, and other health facilities. Researchers agree that the use of EHRs can have many benefits for providers and patients alike, including improved patient outcomes, reduced costs, streamlined administration, and even improved ability to perform medical research.
What Are EHRs?
An EHR is an electronic record of a patient’s medical history that combines test results, diagnoses, and other data accumulated as the patient moves from one provider to another. Your EHR is meant to be longitudinal in nature, meaning that the record represents a lifetime picture of your health history.
Unlike a medical record, which is maintained by a single provider, an EHR is comprehensive; since it includes information compiled from every provider who works with you, it will offer each provider all of the information necessary to make your next treatment decision. That means no more re-ordering an expensive test you’ve already taken somewhere else, and no more waiting for test results to be faxed over from another doctor’s office.
Advantages of EHRs
Ideally, EHRs will someday travel with you. When all providers have made the transition to using EHR systems such as RevenueXL, you’ll be able to get the same quality of care from providers anywhere in the country. They’ll simply be able to check your EHR for pertinent medical information, and even update it so that your providers back home will be able to adjust your care accordingly. Even if you’re incapacitated, your EHR will ensure that providers around the country will be alerted to your medication list and existing medical conditions.
EHRs should make life easier for everyone involved in your care. You’ll be able to:
Schedule doctor’s appointments online
Ask medical questions via email
Request prescription refills electronically
Access test results whenever you want
Keep track of scheduled appointments
The use of EHRs should streamline the many administrative tasks associated with patient care. EHR system software will prompt your doctor to file necessary Medicare and insurance paperwork, will help them keep track of which best practice guidelines apply to your specific case, and will reduce numerous costs.
With the yearly bluster and promise of HIMSS, I still find there have been few strides in solving interoperability. Many speakers will extol the next big thing in healthcare system connectivity and large EHR vendors will swear their size fits all and with the wave of video demo, interoperability is declared cured. Long live proprietary solutions, down with system integration and collaboration. Healthcare IT, reborn into the latest vendor initiative, costing billions of dollars and who knows how many thousands of lives.
Physicians’ satisfaction with electronic health record (EHR) systems has declined by nearly 30 percentage points over the last five years, according to a 2015 survey of 940 physicians conducted by the American Medical Association (AMA) and American EHR Partners. The survey found 34 percent of respondents said they were satisfied or very satisfied with their EHR systems, compared with 61 percent of respondents in a similar survey conducted five years ago.
Specifically, the survey found:
42 percent of respondents described their EHR system’s ability to improve efficiency as difficult or very difficult;
43 percent of respondents said they were still addressing productivity challenges related to their EHR system;
54 percent of respondents said their EHR system increased total operating costs; and
72 percent of respondents described their EHR system’s ability to decrease workload as difficult or very difficult.
Whether in the presidential election campaign or at HIMSS, outside of the convention center hype, our abilities are confined by real world facts. Widespread implementation of EHRs have been driven by physician and hospital incentives from the HITECH Act with the laudable goals of improving quality, reducing costs, and engaging patients in their healthcare decisions. All of these goals are dependent on readily available access to patient information.
Whether the access is required by a health professional or a computers’ algorithm generating alerts concerning data, potential adverse events, medication interactions or routine health screenings, healthcare systems have been designed to connect various health data stores. The design and connection of various databases can become the limiting factor for patient safety, efficiency and user experiences in EHR systems.
Healthcare, and the increasing amount of data being collected to manage the individual, as well as patient populations, is a complex and evolving specialty of medicine. The health information systems used to manage the flow of patient data adds additional complexity with no one system or implementation being the single best solution for any given physician or hospital. Even within the same EHR, implementation decisions impact how healthcare professional workflow and care delivery are restructured to meet the constraints and demands of these data systems.
Physicians and nurses have long uncovered the limitations and barriers EHRs have brought to the trenches of clinical care. Cumbersome interfaces, limited choices for data entry and implementation decisions have increased clinical workloads and added numerous additional warnings which can lead to alert fatigue. Concerns have also been raised for patient safety when critical patient information cannot be located in a timely fashion.
Solving these challenges and developing expansive solutions to improve healthcare delivery, quality and efficiency depends on accessing and connecting data that resides in numerous, often disconnected health data systems located within a single office or spanning across geographically distributed care locations including patients’ homes. With changes in reimbursement from a pay for procedure to a pay for performance model, an understanding of technical solutions and their implementation impacts quality, finances, engagement and patient satisfaction.