If there’s a topic in healthcare IT that has absorbed more ink over the past decade than “interoperability,” I can’t imagine what it would be. (Well, going back to 2009, “meaningful use” may rank a close second.)
The federal government has taken a significant interest in advancing health IT interoperability. For instance, Title IV of the 21st Century Cures Act is all about it, and in 2020 ONC promulgated rules designed to push the industry along to make interoperability a practical reality. One specific way is through an application programming interface (API) approach that “supports health care providers’ independence to choose the ‘provider-facing’ third-party services they want to use to interact with the certified API technology they have acquired.”
But, generally speaking, government mandates have paved a slow and bumpy road to any health IT goal. They focus on rules and regulations rather than incentives (admittedly, meaningful use was a different case). And thus far, that has been the fate of interoperability.
The metaphor our parent company, Commure, uses to describe healthcare today is a city without roads. We built the “city” of healthcare, populated with over 3,000 healthcare IT companies, without considering the pathways that would connect them. Healthcare lacks the proper infrastructure and connectivity to collect and serve up data in ways that will meaningfully transform the way care is accessed, coordinated, delivered, and experienced.
I believe healthcare IT is, at long last, on the cusp of finally realizing the much-hyped, yet elusive promise of true interoperability. Why now? Because of the cloud, and cloud vendors’ embrace of open standards in their APIs, notably FHIR.
After all that transpired in 2020, it’s understandable if people are reluctant to make predictions about what will happen in 2021. I suspect some prognosticators retired their crystal balls, or at least are finding the view a bit hazy right now.
And yet, in the healthcare IT domain, I’d argue that the major trends entering 2020 continued – some even accelerated – during the unpredicted chaos of last year. The movements in health IT toward greater mobility, interoperability, and remote care capabilities all manifested themselves in profound ways during the pandemic. Each will remain a priority for provider organizations in 2021, and I predict (warily) will see progress in the coming year.
Even as mobile devices have become more commonplace in healthcare settings, provider organizations still face challenges in realizing the full potential of these platforms. While there is utility in the ability to view clinical results or send messages (hopefully HIPAA-compliant ones) to colleagues, the real value is to integrate these features into a larger bundle of capabilities central to common provider workflows. Doing so places the entire technological ecosystem in the palm of a clinician’s hand. I predict we will see continued feature growth in the mobile space to better facilitate a provider’s ability to deliver care in the moment, wherever and whenever that moment may be.
To highlight where this evolution of mobility is leading us, consider this scenario. A provider reviews a concerning test or lab result on their phone. Without waiting to address this on a desktop station, they can utilize CPOE on their mobile device to order a follow-up study, and request a notification be “pushed” to them when the study is completed (or there is no result in timely fashion). They can query their fully-integrated messaging feature to identify the appropriate specialist on call and immediately send a secure text, which automatically incorporates a link to the patient’s full chart and all relevant data, and offers the user the ability to add a few lines of text to clarify the reason for consultation. The attending can confirm consult receipt and may further discuss the care plan. The consultant in turn may enter preliminary orders while the attending can message the larger care team (nurse, case manager, etc.) with an update before dictating a quick note.
With the continued advances in NLP and note automation, I anticipate the provider component of note generation will once again focus on pertinent positives/negatives, thought process and the plan, leaving the more administrative documentation to the system. Taken together, these advances will help free the provider from the constraints of the desktop terminal and facilitate the advancement of care. I don’t expect all of this to come to fruition in 2021, but we will take initial steps along the path.
Finally, on the mobile front, I would expect to see continued development of virtual assistants, which will one day move us from simple screen navigation to CPOE and touch-free engagement.
With all that the healthcare system has to worry about these days, perhaps it’s time to hit the “Pause” button on health IT deployment.
While it’s certainly true that provider organizations can ill afford any disruption or downtime in their health IT infrastructure right now – one could argue a massive EHR replacement project might not be advisable at this moment – it’s equally true that effective, practical health IT is needed now more than ever. Clinicians on the front lines of the COVID-19 response need accurate and relevant patient data from the EHR system, instantly (meaning with one click, not dozens); and they need to be able to collaborate with their colleagues on urgent patient care issues at a moment’s notice, anytime, anywhere.
To that end, nothing could be more practical or timely amidst the COVID-19 patient surge than patient data access and care team collaboration capabilities on mobile devices. Smartphones and tablets are the information access and communication tools of choice for most clinicians, wherever they may be – within the hospital, in a triage tent, quarantined at home, or anywhere in between.
But for hospitals under the gun in the midst of this pandemic, is implementing such functionality really feasible?
Let’s back up, and consider a fundamental truth of healthcare IT: EHRs aren’t supporting doctors the way they were intended to, and are diverting valuable time that could be spent with patients.
Ironically, before the EHR, a physician’s biggest pain point was not having access to enough data. Patient information was siloed, typically in dusty paper charts buried in the basement or out of reach in off-site storage. Physicians didn’t have a comprehensive view of the patient. Now with EHRs, providers should have better access to patient information. Alas, that often is not the case, as vital information is buried in a sea of redundant or irrelevant data within electronic clinical notes.
It is crucial that the healthcare industry empowers physicians with tools that will make them better. Unfortunately, forcing physicians to wait their turn for one of too-few hospital workstations is not making them better. The inexplicable persistence of UIs that fail to effectively parse information in a manner consistent with a physician’s workflow or thought process isn’t helping. Obtrusive, non-emergent automated queries that foster alarm fatigue aren’t helping. System design predicated on a one-size-fits-all user experience strategy hinders delivery of care.
On the other hand, well-designed mobile apps, which afford ready and actionable access to relevant patient data, can accelerate care. And if such apps are (a) an extension of the existing EHR, and (b) as intuitive to use as any consumer app on your phone today, then training and adoption shouldn’t be a problem.
The value of “mobilizing” the hospital EHR goes far beyond effectively caring for patients under crisis conditions. It has become essential for provider collaboration on patient care generally, as physicians today are as “siloed” as patient records once were. We are not all in the same hospital at the same time. Remote access to records and the ability to easily communicate with each other within the context of a patient chart are key to the kind of collaboration that fosters better care.
The news on physician burnout lately has been mixed. A 2018 Massachusetts Medical Society/Harvard report received considerable attention – it proclaimed physician burnout has become a crisis, widespread in the medical profession, driven by rapid changes in health care and physicians’ professional environment. Yet last month a study published in Mayo Clinic Proceedings found that physician burnout actually declined more than 10 percentage points from 2014 to 2017, though the rate for doctors was still considerably higher than for U.S. workers at large. And just last week, an American Academy of Family Physicians survey reported that 71 percent of practicing physicians are happy, albeit frustrated by the extent to which administrative and clerical tasks have become part of their daily work.
What to make of all this seemingly contradictory data?
When I began practicing as a hospitalist in the 1990s, the administrative burden on physicians was much less than today, owing in part to the regulations and routine processes of the day and the typical patient caseload. Back then I saw 12 patients per day. With that caseload, you could break even on billing while still having plenty of time to interact with patients and colleagues. While it would not be feasible to return to that volume today, the point is that the hospital afforded a much more professionally rewarding environment. There was time to discuss interesting cases with colleagues. There was time to revisit patients and dig deeper into their records. You had time to sit at a patient’s bedside and hold their hand. The pace today does not afford this opportunity, much to the dissatisfaction of physicians. The resulting isolation from patients and peers is a contributing factor to the burnout seen among physicians.
Then there’s the technology component. EHRs are widely regarded as a significant cause of physician stress and a distraction from patient care. For example, when hospitals installed computerized order entry (CPOE), it eliminated the order clerk and created an additional job for the physician. The evolution of the clinical note is another example of unintended clinical burden, with roots in the evolution of medical practice and the emergence of EHRs.
Take a step back and consider what the original purpose of a physician’s note was: to advance patient care. The note would be updated on a visit-to-visit basis by the same physician or perhaps another physician in the same group covering a weekend. Then shift-based medicine came into play, and the note became a vital mechanism to facilitate care transitions. Then, as malpractice suits became more commonplace, lawyers began requiring physician documentation to support their legal case. From there, we saw the note transform from a clinical and legal document to a billing document and a check for RAC audits.
Given these trends, the pressure on provider organizations (and physicians individually) to document extensively and bill correctly for every service performed has grown over time. Concurrently, the practice of regularly reconciling clinical notes and charges also has grown in importance, both to identify missing charges (for revenue enhancement) and to identify missing notes (for compliance). In order that this process doesn’t become another straw on a physician’s administrative back, many organizations prefer to automate charge-note reconciliation within the revenue cycle management workflow.
For a variety of compelling business reasons, not limited to concerns about physician burnout, healthcare systems must attend to their physician experience with the same level of care and intention as their patient experience. Here are three ways that improving physician experience can help to bolster a hospital’s bottom line:
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.”
Vice President Joe Biden recently took the stage at Health Datapalooza in Washington, D.C. to discuss where healthcare technology currently stands, and he didn’t hold back. Among other things, he chastised the industry for poor health IT system interoperability and the resulting difficulties it causes providers and patients. “We have to ask ourselves, why are we not progressing more rapidly?” Biden lamented.
Biden’s criticism is only the latest high-profile commentary about the unfulfilled promise of information technology in healthcare. AMA leaders and individual physicians have been grousing about it for years. We’ve seen technology increase efficiency, reduce costs and improve productivity in every other industry – but why not healthcare?
Ironically, seven years after the passage of the HITECH Act of 2009, doctors are less productive than they were before, and IT is the culprit. Rather than enabling a better, more streamlined workflow, IT has become a burden.
The drag that IT is placing on healthcare providers is a principal reason why U.S. Health and Human Services (HHS) Secretary Sylvia Burwell announced with great fanfare at the HIMSS16 conference an “interoperability pledge,” which vendors and providers alike are encouraged to take. Its purpose in part is “to help consumers easily and securely access their electronic health information, direct it to any desired location, learn how their information can be shared and used, and be assured that this information will be effectively and safely used to benefit their health and that of their community.”
This call resonates because the promise of better healthcare through technology has been broken. Technology has changed the way we communicate, the way we shop, the way we watch TV, the way we drive, and the way we interact with our homes. As an industry, healthcare is lagging way behind. The consequences are drastic. In order for us to deliver the kind of holistic care that will truly improve people’s health, it’s time not only to talk about the potential, but to make it a reality for users and providers across the healthcare continuum.
Here’s the reality: we have today what 10 years ago was called a supercomputer in front of physicians – a device that knows virtually everything about the patient – but it isn’t helping out in ways that we take for granted in our everyday lives when we shop online, use Google Maps or order an Uber.
Guest post by Amy Sullivan, vice president of revenue cycle sales, PatientKeeper.
The multi-year run-up to the ICD-10 cut-over last October had a “Chicken Little” quality to it. There was prolonged hand-wringing and hoopla about the prospect of providers losing revenue and payers not processing and paying claims – the healthcare industry equivalent of “the sky is falling.”
Then CMS helped calm things down by announcing last July (as the AMA reported at the time), “For the first year ICD-10 is in place, Medicare claims will not be denied solely based on the specificity of the diagnosis codes as long as they are from the appropriate family of ICD-10 codes.”
Since ICD-10 is all about specificity – the number of diagnosis codes increased approximately four-fold over ICD-9 – this was a big relief to all involved. And, if you believe new research data, the sky indeed has not fallen: Sixty percent of survey respondents “did not see any impact on their monthly revenue following Oct. 1, 2015… Denial rates have remained the same for 45 percent of respondents. An additional 44 percent have seen an increase of less than 10 percent.”
Still one has to wonder what will happen after Oct. 1, 2016, when the current leniency expires and ICD-10 code specificity is required. Will physicians be in a position to enter their charges completely and accurately once “in the general neighborhood” coding no longer suffices?
They will if their organization has invested in technology that adheres to best practices in electronic charge capture system design. The three watch-words are: specialize, simplify and streamline.
A charge capture system is specialized when it exposes only relevant codes to physicians in a particular specialty or department, and when it provides fine-tuned code edits. With different types and processes of workflows (and let’s face it, personal preferences), physicians need an intuitive and personalized application that easily fits into their individual work styles. A tailored user experience allows providers to build and display their patient lists in whatever way is most convenient and meaningful to them – down to lists organized by diagnosis and “favorites.”
Health IT’s most pressing issues may be so prevalent that they can’t be contained to a single post, as is obvious here, the third installment in the series detailing some of the biggest IT issues. There are differing opinions as to what the most important issues are, but there are many clear and overwhelming problems for the sector. Data, security, interoperability and compliance are some of the more obvious, according to the following experts, but those are not all, as you likely know and we’ll continue to see.
Here, we continue to offer the perspective of some of healthcare’s insiders who offer their opinions on health IT’s greatest problems and where we should be spending a good deal, if not most, of our focus. If you’d like to read the first installment in the series, go here: Health IT’s Most Pressing Issues and Health IT’s Most Pressing Issues (Part 2). Also, feel free to let us know if you agree with the following, or add what you think are some of the sector’s biggest boondoggles.
The healthcare industry has undoubtedly become a bigger target for security threats and data breaches in recent years and in my opinion that can be attributed in large part to the industry’s movement to virtualization and the cloud. By adopting these agile, effective and cost-effective modern technological trends, it also widens the network’s attack surface area, and in turn, raises the potential risk for security threats.
We actually conducted some research recently that addresses evolving security challenges, including those impacting the healthcare industry, with the introduction of cloud infrastructures. The issue is highlighted by the fact that the growing popularity of cloud adoption has been identified as one of the key reasons IT and security professionals (57 percent) find securing their networks more difficult today than two years ago.
Paul Brient, CEO, PatientKeeper, Inc. No industry on Earth has computerized its operations with a goal to reduce productivity and efficiency. That would be absurd. Yet we see countless articles and complaints by physicians about the fact that computerization of their workflows has made them less productive, less efficient and potentially less effective. An EHR is supposed to “automate and streamline the clinician’s workflow.” But does it really? Unfortunately, no. At least not yet. Impediments to using hospital EHRs demand attention because physicians are by far the most expensive and limited resource in the healthcare system. Hopefully, the next few years will bring about the innovation and new approaches necessary to make EHRs truly work for physicians. Otherwise, the $36 billion and the countless hours hospitals across the country have spent implementing electronic systems will have been squandered.
Email security is one of healthcare’s top IT issues, thanks, in part, to budget constraints. Many healthcare organizations have already allocated the majority of IT dollars to improving systems that manage electronic patient records in order to meet HIPAA compliance. As such, data security may fall to the wayside, leaving sensitive customer information vulnerable to sophisticated cyber-attacks that combine social engineering and spear-phishing to penetrate organizations’ networks and steal critical data. Most of the major data breaches that have occurred over the past year have been initiated by this type of email-based threat. The only defense against this level of attack is a layered approach to security, which has evolved beyond traditional email security solutions that may have been adequate a few years ago, but are no longer a match for highly-targeted spear-phishing attacks.
Dr. Rae Hayward, HCISPP, director of education and training at (ISC)²
Dr. Rae Hayward
According to the 2015 (ISC)² Global Information Security Workforce Study, global healthcare industry professionals identified the following top security threats as the most concerning: malware (77 percent), application vulnerabilities (74 percent), configuration mistakes/oversights (70 percent), mobile devices (69 percent) and faulty network/system configuration (65 percent). Also, customer privacy violations, damage to the organization’s reputation and breach of laws and regulations were ranked equally as top priorities for healthcare IT security professionals.
So what do these professionals believe will help to resolve these issues? Healthcare respondents believe that network monitoring and intelligence (76 percent), along with improved intrusion detection and prevention technologies (73 percent) are security technologies that will provide significant improvements to the security posture of their organizations. Other research shows that having a business continuity management plan involved in remediation efforts will help to reduce the costs associated with a breach. Having a formal incident response plan in place prior to any incident decreases the average cost of the data breach. A strong security posture decreases not only incidents, but also the loss of data when a breach occurs.