This article appears in the February 2012 issue of HealthLeaders magazine.
Although the title of chief nursing informatics officer or nurse informaticist isn't exactly commonplace, data is increasingly becoming a part of nurses' day-to-day working lives. Typically the largest employee population, nurses also have the most frequent direct contact with patients. And so getting data into their hands can have a big impact on patient care.
"Every nurse needs to be able to understand the power of data, because nurses are knowledge workers. We have always collected data and information. So we need to understand the data that's at our fingertips. It's something that every staff nurse should be able to do," says Toni Hebda, PhD, RN, BSN, MNEd, MSIS, a professor in the master of science nursing degree program at Chamberlain College of Nursing, which has campuses in seven states and is headquartered in Downers Grove, IL.
"For us to be adept at what we need to do, we need to be able to work with the technology and use it at the optimal level so that we can reap the benefits, both for our work methods, as well as patient safety and improved outcomes," she says.
Still, some say adding a chief nursing information officer to the executive team is another example of C-suite bloat.
And Hebda agrees that not every department in the hospital needs a chief informatics officer. But she adds that it is a mistake to think that informatics should be solely the domain of doctors.
"From a political standpoint, a lot of people still prefer to reference 'medical informatics,'" Hebda says. "And some people innocently think that just encompasses everything within the healthcare profession," although in industry-speak that phrase refers to physicians. "There are many areas within healthcare or medical informatics that represent the different disciplines," she says.
That attitude isn't an issue at the 330-licensed-bed Catholic Medical Center in Manchester, NH, says Mercedes Fleming, the organization's manager of nursing systems and support.
"I've mostly worked at community hospitals. And honestly my experience is that at community hospitals the nurse has tremendous autonomy. And the doctors here are actually accustomed to nursing taking a leadership role in caring for the patient. I'm not saying we operate outside our scope of practice. But we do keep a pretty close watch over what is going on with our patients. That's really nothing new for us," she says.
Resources and responsibilities
CMC started its nursing informatics work in 2007 with a clinical documentation system—it used a knowledge-based charting program that merges evidence-based practice and clinical practice guidelines.
"It dramatically improved the quality of the documentation and put all nurses on the same page in terms of caring for the patients," she says. "It moved all nurses to that same level of care."
The program, a product by Grand Rapids, MI–based software firm Elsevier CPM, measures patient outcomes by asking nurses to determine the patient's condition—if it is improving, declining, or stable.
"That was a higher level of practice than we had employed prior to that time," she says.
Then the hospital decided to make its nurses experts in a number of different systems, starting with computerized physician order entry.
"We are a community hospital so we don't own most of our medical staff. And being community-based, we had to come up with a different strategy [for CPOE]. We thought that if all of our nurses became experts in the system first, then they would support the medical staff," Fleming says. "Nursing really has provided a great deal of support for medicine."
Empowering nurses in this way has also led to innovation, particularly in the design arena. Involving the end user in design is critical, she says. "People make the assumption that [if] you're electronic, you're automatically safer. That is not true." Poor design leads to as many or more errors as existed in a paper world, except that in the digital world "the errors happen faster," she says.
"The nurses and department coordinators will come up with things that nobody else has thought of," she says.
Jennifer Torosian, RN, MSN, NE-BC, administrative director of nursing services at CMC, agrees that there's a huge benefit to giving nurses that kind of responsibility. At CMC, when nurses have a concern, they don't hesitate to take it to the administration, in part because "they really believe we're going to do something about it," she says.
In some cases, the hospital was doing the right thing—such as removing catheters on time—but just wasn't proving it. Data helped there, too.
"We're pulling from the Foley insertion date. We need to work with nursing and make sure the nurses know how important it is to document the date," Torosian says.
Now the organization can run a report to calculate catheter days with an insertion date and a removal date. "I can go on at any time and print out and see how many patients in-house have catheters, the date they were inserted, and the date they were removed. And I can also see if one of the nurses hasn't documented an insertion date and work with the nurses to give them the feedback and the education that this is really important," Torosian says.
"It's definitely giving us a good starting point. We're able to give fairly close to real-time feedback. It's just a matter of figuring out who's going to monitor those reports," she says. "It's great that you have all these reports, [but] who validates? How are you going to validate the data, and who's going to monitor it and run the reports? I think we've done a great job in empowering the department coordinators to do that."
"We have seen a significant decrease in the number of missing insertion dates. Previously, on any given day we would have on average six patients on the report with no insertion date; we are down to an average of two," Torosian says.
Nurses are also doing a better job completing patient profiles. A year ago there could be 15 incomplete patient profiles in one month. That number steadily declined over the year—and in November 2011, there were no incomplete patient profiles for the month.
Order reconciliation is another area where informatics has made dramatic improvements, says Fleming.
On admission, nurses enter patients' historical or home medications. "Medication reconciliation has always been a challenge, but now the nurses are entering historical medications with the expectations that they are accurate, allowing the attending provider to convert it to an inpatient order. The nurse makes every attempt to confirm the correct medication, dose, unit of measure, frequency, how the medication was prescribed, and how the patient is actually taking it—all of that information is critical," Fleming says.
Accurate medication reconciliation has a significant impact on patient outcomes and readmissions at CMC.
"When we're able to accurately identify the patient's home medications, the provider can more effectively order medications during the patient's hospitalization and on discharge. Accurate admission and discharge reconciliation positively impacts patient outcomes, and nursing is responsible for a large part of that." Fleming says. "Nursing does not perform the reconciliation, but the quality of the historical information they gather can directly impact the patient as well as the efficiency and accuracy of the provider."
The shift from paper to electronic records has transformed the process. "On paper, the nurse or provider was free to leave key prescribing information blank on the home medications list." Fleming says. "With electronic historical medication entry, the nurse is guided to complete all elements of a complete historical medication order. The nurses are now routinely following up with PCP offices and home pharmacies to determine the correct and complete home medication information."
CMC reports that the improvements are leading to better quality. For example, CMC has decreasing door-to-balloon times, and its key performance indicator scores have exceeded expectations, with 44 excellent and 28 notable scores. CMC achieved best practice thresholds in 72 KPI categories.
And improving clinical documentation has had a positive financial impact. By decreasing lost billable charges, the organization's emergency department increased revenue by 48% in the first 6 months, and continues to see appreciable monthly increases in expected revenue capture. Total overall charge capture for FY2011 showed an average monthly increase of 33%.
Unlocking the data
Oklahoma Heart Hospital bills itself as one of the nation's first all-digital hospitals. But like many organizations that are early adopters of electronic medical records and other health IT systems, the organization's leaders were struggling to figure out how to make better use of it.
"We had this great EMR that had all this data that we couldn't get out very easily," says CIO Steve Miller.
So the 145-staffed-bed Oklahoma City organization, which encompasses two campuses and 60 affiliated clinics, started investigating how to use technology to unlock that data, make it actionable, and get it into nurses' and physicians' hands.
Today, the organization uses a number of techniques and technologies to improve clinical quality, workflow, and patient satisfaction.
Getting alerts on the go
"A lot of hospitals spend a large amount of time and personnel around centralized monitoring," Miller says. "Most hospitals have a centralized monitoring room where you'll have dozens and dozens and dozens of monitors and a 24/7 staff who are just sitting there staring at the monitors waiting for critical alerts."
Instead, Oklahoma Heart Hospital sends near-real-time critical alerts from hardwired heart and vital-sign monitors directly to nurses' smartphones using an integration engine from Boulder, CO–based Connexall USA.
The mobile alerts include an image of the patient's heart rhythm so the nurse can evaluate the severity of the alert. (If for some reason the patient's assigned nurse does not respond, the alert automatically escalates to another caregiver.)
Of course, monitors still give alerts in patients' rooms and at nursing stations. "But in our facility, nurses could be in another room taking care of patients. So the idea was to give them the best possible way to know as quickly as possible that there's an alert. You don't want to wait till the next time you're at that nurses' station or rely on hearing it in the room," Miller says.
The system allows nurses to not only spend more time at the bedside but also respond to patients more quickly, says Janet Fundaro, APRN-CNP, chief nursing officer. And the facility's EMR allows nurses to perform documentation faster, as well. She encourages nurses to document in the room while they're with the patient. It's more efficient and accurate, and also presents a chance to talk to and educate the patient about his or her care.
"That does help with our patient satisfaction because of the quality and quantity of time," Fundaro says.
Integration with the organization's EMR is another important piece of the alerting system. "Inside our EMR, we have multiple alerts that are designed to really help stay ahead of all the factors that may contribute to the overall care of that patient," Miller says. Alerts automatically generated from EMR data include risk for infections, falls, out-of-range lab values, and more.
"We try to make our alerts as automated as we can because that's where you can get value," Miller says. "The No. 1 [advantage] is to be able to take care of the patient in any kind of critical situation as quickly as possible … to respond to that patient and provide whatever they need as quickly as possible."
The organization plans to expand its mobile alerting system. "We're looking at integrating more of our EMR alerts that today go to them in the charts and instead send those to the smartphone," Miller says.
Assessing acuity
At the 624-staffed-bed Mission Hospital in Asheville, NC, nurses use informatics to classify the acuity of every patient on every unit every day. That data tells them how many hours of care each patient will need so that they can deploy staff accordingly.
"You can look at the acuity of every patient every day," says Brenda Shuford, RN, management systems coordinator. "The nurse on the unit providing the care to the patient that day goes in and does what we call a classification of her patients. So there are certain indicators that are weighted based on how valuable they are in translating the needs of the patient into their hours of care that were needed for the day … Once they get all the patients on that unit classified, they're able to run a report and see what kind of staffing recommendations they're going to need for the next shift."
When Shuford was a nurse manager in the pediatric ICU, she instinctively knew that although the number of patients in any given unit didn't change dramatically over time, the severity of illness did. "And the staffing—hiring and change of mix—had not kept current to the patient changes," she adds.
But when Shuford asked for more RNs and a change in skill mix on the units, the answer was no. Budgets are created based on patient days and because the historic data on patient days hadn't changed, neither would the nursing staff configuration or budget.
Using an acuity system by Reston, VA–based QuadraMed when she became management system coordinator, Shuford and her team tracked patient data for two years and ultimately convinced finance leaders to create parallel budgets—one based on acuity system data and one based on historical data.
It turned out the acuity assessment–based budget and the historical budget weren't so different. The former would save the organization just one half of a full-time equivalent position. But although staff levels stayed more or less the same, nurses are now deployed where they are most needed each day.
"It really did show … the units that were overstaffed and the units that were understaffed," Shuford says.
"We knew the nurses knew what staff they needed. They just needed some way to prove that. And the QuadraMed system gave that opportunity to prove that. Nurses really know from being there a few hours what the flow of patients is and how sick they are and whether they've got the right number of staff. Being able to respond and get the finance end of the healthcare business to understand and see that nurses need to be in charge of that was an issue. But with this system we were really able to accomplish that," Shuford says.
Better deployment of resources had an impact on satisfaction, as well.
"We increased not only our staff satisfaction, which had been really low in the pediatric ICU because of the feeling of being overworked, but also patient and family satisfaction," Shuford says. "Before we got the additional staffing, I had numerous conversations with families who were disgruntled that their child did not get the care that they needed at the time that they needed it—it wasn't a timely response."
The assessment takes a nurse who is familiar with the system and its indicators about 20 seconds per patient.
Ultimately, the organization plans to automatically send the Cerner documentation system to the organization's QuadraMed indicators and classification system, saving nurses from having to enter the data twice.
That's one of the areas where nurse informatics can shine, Hebda says. An automated systems that asks nurses to enter the same piece of information numerous times "is clearly a waste of everyone's time," she says. "Nurses are already in short supply, and they know that this is a waste of their valuable time. And if you're already collecting the data once, then the screen capture should bring that information into other programs [and] automatically populate it everywhere."
Acuity data has led to significant staffing changes in several Mission Hospital departments. The surgical unit, for example, used workflow data to make the case for a dedicated discharge nurse who would work peak discharge hours: Monday through Friday from 8 a.m. to 4 p.m.
That allows other nurses to focus on caring for new admissions, Shuford says, and "reduces the chance of error from interruptions." In fact, the surgical unit's readmission rates have decreased from 8.23% to 8.00%, although several initiatives were occurring during this time to reduce readmissions.
In the ED, acuity data was used to make the case for staggered shifts throughout the day with overlap at peaks in volume. Every unit management team has access to the data and can use it to make similar decisions about staffing and other solutions.
Prior to utilizing the acuity data to modify the staffing patterns, the ED provided staffing within the target range only 12.5% of the hours of the day. Since implementation of staggered staffing based on acuity data by hour of day and day of week, they are now providing staffing within the target range 54% of the hours of the day, Shuford says. They are continuing to adjust shift hours to further increase this percentage.
Putting data in plain view
The ability to view alerts and other clinical data in dashboard format also makes it easier for nurses to respond quickly "in a way that we were never able to do in the past," says Oklahoma Heart Hospital's Miller.
The MPages Web-based platform from Kansas City, MO–based Cerner helps keep track of vaccines, stroke indicators, aspirin on arrival, rehabilitation references, venous thromboembolism, restraints, and dietary needs, for example, arranging the information for nurses in an easy-to-read format.
"Most of the data is near real-time in that it is information about patients who are currently in the hospital. It's information about actions that we either have performed or need to perform on those patients," Miller says.
The organization also uses its EMR reports and dashboards to track progress toward goals such as CPOE use and meaningful use readiness.
"We had CPOE; we already had a lot of those meaningful use measures. But we really needed a way to track our percentages and look at that information in much greater detail to ensure we were really meeting the meaningful use standards," Miller says.
"I looked at all these meaningful use measures and I said, 'How are we ever going to know that we're doing all this?' I really have confidence when the CEO comes to me and says, 'Are we going to make meaningful use? Are we going to get a little bit of that EMR investment back so we can reinvest in other areas?' And I can say, 'Absolutely.' I know we're doing this and that we're doing the best job for our patients.
"That's why we started this process, but it really led us to this whole better way to consume information that is, we think, really going to revolutionize our area," Miller says. "This ability to build dashboards and to present data in much more than just lists but to be able to show it in dials, to be able to show it with more graphics, to be able to put that not only on a traditional interface, but put that into an iPhone or put that into an iPad—that ability to bring data out and provide that in a much more meaningful way—that's really changed the way we do business."
The data has also changed the way that the organization serves its patients.
"We are beginning to see information so much clearer than we could in the past. That's really been the innovator for us," Miller says. "We're really focused on making information more useable. And so I think for us we have the data and now we have the tools to present it. Really focusing on that usability engineering in everything we do is a big part of our strategy."
And that applies to both clinical information and business information. "Being able to use that more effectively to run our business is going to be very core to the future," Miller says. "The challenges of healthcare are so large … the ability to use data and information to help us chart the way and become more efficient, to find out ways to improve the cost or the value that we're delivering to that patient, is absolutely paramount."
This article appears in the February 2012 issue of HealthLeaders magazine.
This article appears in the December 2011 issue of HealthLeaders magazine.
Ellis M. Knight, MD, MBA, went into medicine as an idealist. And, added the senior vice president of ambulatory services at Palmetto Health in Columbia, SC, he still is.
But about five years ago he began to question whether his practice of medicine was measuring up to the expectations, desires, and motivations he had when he entered medical school.
The answer: not so much. It was “crushing,” he said at the HealthLeaders Media Rounds event, The Real Value of ACOs, hosted by Norton Healthcare in Louisville, KY.
“I went into a career in medicine because I wanted to help people, [but] a lot of what I was doing every day wasn’t helping people. I was doing a lot of stuff, seeing a lot of patients, putting people through a lot of tests and procedures, a lot of stays in the hospital, but when you asked at the end of the day how much good I did for people today, what did all this activity result in? My honest assessment was not as much as I’d like.”
Knight thought the answer to this lacking might lie in a system of accountable care. To his surprise, he discovered many of his colleagues felt the same way. In the summer of 2009, Knight sent an e-mail to physician colleagues and asked them what they thought about starting an ACO. The positive response was overwhelming. Ultimately there were well over 100 physicians on the e-mail chain.
The Palmetto Health Quality Collaborative was created in 2010 to align the acute care hospital system with the medical staff and community physicians to improve the quality and coordination of care. All physicians who are members in good standing with Palmetto Health are eligible to participate—including employed, contract, and community physicians.
“Integration at several levels is something that we worked on a lot at Palmetto Health Collaborative,” Knight said.
To succeed, accountable care–type organizations should consider focus on culture as well as clinical and economic integration.
Cultural integration, Knight said, is not only the most important aspect, but also the most difficult to achieve.
Knight harkens back to that e-mail—it was exciting, he said, because it shows that even physicians who are practicing independent of each other have a common vision. Common motivation helps form the bedrock of a common mission and vision for an ACO and is the foundation for establishing trust and breaking down barriers between key players.
“The piece that is really essential to accountable care is to bring physicians and healthcare systems together in a way that they’ve never been before,” Knight said. “To really bring physicians into your business model requires a lot more than a contract and a paycheck.”
And integration needs to be more than clinical: Physicians must also be an integral part of the business model, he said. And that means more than compensation and employment, he added, but bringing together physicians who don’t all work for the same organization.
“Systems and physicians that don’t have employer-employee relationships [can] come together and economically integrate in ways that previously would have been frowned on, that would have raised issues with regard to antitrust.”
In addition to advice about what organizations should do to succeed, Knight offered the audience a list of four traps to avoid.
For starters, he said, don’t think it will be easy. “It is changing a culture that has been longstanding and well-entrenched, and that is never easy.
“Also, don’t think that there’s a standard way to do this. There is no evidence-based best practice out there that you can pull out of the literature and say, ‘Aha, here it is.’” Collaboration with other organizations that are also experimenting with the model can help.
Don’t wait until things have gotten so bad that there has to be a political or legislative solution. If that happens, “things could get real ugly real fast,” he said. “We have got to act, and we’ve got to act quickly.”
Finally, Knight said, don’t think it’s not worth it. “I believe healthcare is a calling. I believe that those of us who chose this as a profession did so because we had some very noble aspirations, and I think developing accountable care organizations can be a way that we can realize those dreams and create an environment where we can find true fulfillment and also provide the kind of care and the kind of services that out patients deserve.”
This article appears in the December 2011 issue of HealthLeaders magazine.
Years ago (Google it if you really want to know how old I am), one of my favorite Boston Globe columnists wrote an occasional "I was just thinking" feature, a series of pithy observations on various random topics. And although it was widely believed that Mike Barnicle only wrote these roundup columns when he was out of ideas or just feeling lazy, I always liked them. And I always thought it would be fun to write one, too.
Of course, Barnicle ended up getting fired over one of those columns, in which he quoted without attribution from a book by comedian George Carlin. He did some other bad reporter stuff, too. But I promise I didn't make up or plagiarize any of the following news stories from 2011. (Although I won't comment on whether I'm out of ideas or feeling lazy.)
Reporter milks sprained ankle for page views
Writers know there is an upside when something bad happens—say, a trip to the emergency room halfway through your dream vacation to Paris: There's almost always a story in it. At the time of my visit to the emergency room at the 987-bed Hôpital Bichat–Claude Bernard, I wasn't thinking about the potential for a column.
Until, that is, I discovered they don't even have the capability of printing out discharge instructions in multiple languages, let alone the ability to send digital X-rays and a report of the ED visit to my doctor in the U.S. They did, however, manage to send me a bill for €36. And I was just thinking that I still haven't paid it.
Robots, robots, robots
I probably wrote too many robot stories for HealthLeaders Media during my tenure as senior technology editor. If you Google “Gienna Shaw robots” you get about 18,900,000 results. In my defense, I really like robots. It's clear that robots have been and will continue to be a boon to the healthcare industry—from robot-assisted surgery to remote healthcare. And I was just thinking … I just wrote about robots again.
CMS extends stage 2 meaningful use deadline; industry yawns
It's not really a surprise that the feds, facing industry and political pressure, extended the deadline for hospitals to meet the second phase of meaningful use requirements. But I was just thinking that I won't be so surprised the next time I'm at a tech conference and ask someone what their organization is doing about, say, ICD-10, and the answer is "waiting for the government to extend the deadline."
Gienna Shaw signs off
[Editor’s note: This is Shaw’s last column for HealthLeaders Media, featuring her insights on health IT, personality, and snark. Look for continued coverage of technology from the healthcare CIO perspective on HealthLeadersMedia.com, in HealthLeaders magazine, in the weekly “Technology Input” column and newsletter, and in our multimedia and research-based products.]
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Jim Geary.
This profile was published in the December, 2011 issue of HealthLeaders magazine.
"Support groups are as needed today as they were 25 years ago. There's an array of issues that medical personnel cannot really address or don't have the time to address."
At this very moment across the United States, hospitals are struggling with a series of interconnected challenges: How to get patients more engaged in their care and encourage providers to practice participatory medicine; how to coordinate care along the entire continuum; how to build a care team that includes not only providers and patients, but also family members and advocates; how to incorporate alternative medicines and treatments and spiritual beliefs and practices into the patient's care plan; and how to improve quality during care transitions to improve outcomes and prevent readmissions.
To Jim Geary, these issues are nothing new. He's been challenging the healthcare system to address them for 30 years.
Geary moved to San Francisco in 1974 and he worked for three years as an attendant on an oncology unit. A few years later he was protesting alongside Mayor George Moscone and Supervisor Harvey Milk against the Briggs Initiative, which would have made it mandatory to fire gay teachers and any public school employees who supported gay rights. The measure was defeated. Several weeks later, Moscone and Milk were assassinated.
Geary found some kind of solace as a volunteer for the Shanti Project, a support group for people with life-threatening illnesses. In 1982, while serving as executive director, Geary spearheaded a change in mission, turning Shanti into what's considered the first support agency for the disease that came to be known as AIDS.
(Geary later resigned from the organization amid allegations of nepotism, sexual harassment, and discrimination. Both Geary and the Shanti Project were ultimately cleared of all charges.)
As predominantly gay men were being ravaged by a little-understood virus, they were also being vilified by the public and abandoned by friends and family. Many healthcare workers were not immune to the panic and confusion, donning gowns, masks, and gloves for fear they might catch the virus through the air or by touching a patient. Shanti proved to be not only a key support network for patients, but also played a key role in educating the public and healthcare professionals.
In early 1983, Kaiser Permanente invited Geary and several AIDS patients to tell their stories to doctors, nurses, and other healthcare professionals.
"That was so empowering and so transforming for the healthcare professionals. A lot of them had never seen a person with HIV at the time or interacted with one. Hearing the stories firsthand was a tremendous opportunity for them to dispel a lot of the stereotypes that they had previously held."
The kind of dialogue could help healthcare professionals better treat patients suffering from today's epidemics: obesity, diabetes, and heart disease, for example, he notes.
Geary went from being an activist for all AIDs patients to an advocate for one in 1992, when his own lover of 20 years, Jess Randall, was diagnosed with AIDS. As they navigated the healthcare system together, many of its problems—issues with which the industry still grapples today—became painfully apparent.
About a year before Randall died, he was admitted to the hospital with a high fever and a sepsis infection. That was Geary's first encounter with the dangers inherent in lack of care coordination and patient engagement and empowerment.
Randall's therapy had not been working, but the nurses on the new shift didn't know that—they didn't know Randall—and followed the doctor's standing orders.
"As a lover, I was keenly aware of the dramatic changes that had happened to him within a 24-hour period," Geary says. "I pleaded with the nursing staff to take note of that." Even when he convinced the charge nurse to call the doctor, she wasn't able to clearly communicate the changes in Randall's condition over the past 24 hours because she had not seen them first-hand.
"I called the doctor myself and I said, 'Something's not right—you really need to get in here. I think he's going to have a heart attack or go into respiratory arrest very shortly.'"
The doctor moved Randall to intensive care. But once he was stabilized, nurses wanted resume the same standing orders that Geary believes put Randall in jeopardy. Geary, as Randall's healthcare surrogate—refused the treatment. Geary believes if he had not had the courage to speak up, the treatment would have hastened Randall's death.
Although many believe that stronger physician-patient partnerships could improve quality of care, the old doctor-as-God model is still too common, Geary says.
"Some people are basically arrogant and it is 'physician or head nurse knows best.' When you come up against that it is difficult to assert yourself, particularly in a weakened physical and emotional state to advocate for yourself. I think that was one of the tremendous benefits of Shanti volunteers is that often they could advocate for a patient when the patient was not able to advocate for themselves," he says.
"The majority of healthcare professionals are coming from a caring, loving place and a passionate place, but they get overwhelmed, they get stressed, they get burned out, they work long hours and in managing their time they feel they only have a certain amount to provide each patient. So maybe some of that curtness and that way of dismissing the patient's voice is a result of that."
Even so, healthcare must listen to the patients' voice, he says, and "really connect with that person before us and inquire genuinely about what their needs are and how we can assist them. That may take another minute or so but it just gives the patient such a feeling of comfort and ease when they're seen in that light and they're treated with that type of respect."
Healthcare professionals are often afraid that such emotional connections will lead to burnout—Geary says he understands that and agrees there's a need to set limits.
"In order to be a good doctor or healthcare professional you need to allow yourself to feel to a certain level. You need to put yourself in the shoes of the person you are serving for a few moments. And you need to allow yourself to be affected, emotionally, by their story," he says. "Burnout is when you wall yourself off emotionally—when you're so afraid of connecting with somebody on that heart level, on that emotional level … It's a terrible disconnect from the person you're trying to service."
Healthcare organizations could do a better job of supporting patients in concrete ways, as well.
"Support groups are as needed today as they were 25 years ago," Geary says. "There's an array of issues that medical personnel cannot really address or don't have the time to address. The patient is not necessarily in need of physiological or therapeutic counseling, but they really want to meet someone who has gone through or is going through a similar experience."
Hospitals should play an active role in forming support groups to lessen the alienation that people newly diagnosed with a disease or condition feel, and increase their sense of empowerment, Geary says.
"People don't write grants to create support groups, they just kind of happen willy-nilly. And yet the benefits of them are just tremendous," he says. It would be "wonderful" if these groups were offered in a hospital setting.
"You treat someone at the hospital and then you send them home, and oftentimes you send them to a home where they don't have that type of emotional support available. They don't know other people with the illness. Certainly local AIDS organizations can help with that but a lot of people fall through the cracks," he says.
"This would be a great thing for hospitals to do more of. It's certainly low-cost to them and it would make their patients feel much more secure and probably a lot of the issues just in terms of time management … could so easily be handled within a support group. It would also have the benefit of empowering patients to be able to articulate more clearly what they need from their doctor-patient relationship."
This article appears in the December 2011 issue of HealthLeaders magazine.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Rebecca Lynn.
This profile was published in the December, 2011 issue of HealthLeaders magazine.
"There's been a ton of resistance from the industry because they want to preserve the status quo. And that's typical of any industry that's about ready to be changed and reinvented."
Some argue that the healthcare industry is innovation-proof. It is risk averse. It is too slow—even unwilling—to change. It is too complicated and regulated to reinvent. And it has no incentive to shake things up. The healthcare system is expensive, inefficient, and difficult for its customers to navigate.
It doesn't have to be that way, says Rebecca Lynn, a partner at Morgenthaler Ventures, a venture capital and private equity firm with offices in Menlo Park, CA. But the healthcare industry isn't going to save itself, she adds. Change will come from outsider entrepreneurs unfettered by the status quo—who can tame the healthcare data beast and who are willing to try new ideas, such as outsourcing some care to patients themselves.
Lynn, who has a background in consumer and finance products and services, has turned her attention to investing in companies that are "reinventing healthcare [and] bringing healthcare closer to the patients, that are making doctors more efficient and better able to do their jobs," she says.
It all starts with data, Lynn says. They key is figuring out the best way to get that data into the hands of those that need it: physicians and patients in particular.
"People care more about their financial health than they do their personal health," she says. Even so, "few people are compulsive enough to balance their checkbook." That's why she doesn't believe that patient-managed PHRs will work—because few people will populate and maintain them on their own.
"The only way to get the data is through an EMR—an electronic medical record—that's automatically populated by your physician, by the labs, and by pharma companies," she says. "In order to get the data it's got to be in the cloud and then in order to get access [and] widespread distribution, it has to be free. One thing we've learned is that doctors pay for nothing. It's not a slam against doctors it's just a fact of life."
Lynn was looking to invest in a company that would meet her requirements—an EMR that would be easy to access and populate with data and with a business model that wouldn't scare docs away. She says she found what she was looking for in PracticeFusion, a free, web-based EMR with an open application programming interface that grants access to other applications.
PracticeFusion faced a common problem for startups trying to break into the healthcare business—a painfully long lead time to get products into use. Startups also often struggle to find a business model that will appeal to healthcare organizations—especially those docs who don't want to pay for anything.
Startups must get creative when it comes to revenue models. Offer the product for free and it will "take off like wildfire," she says.
Although they may not be willing to enter their healthcare details on their own, patients, Lynn predicts, will be increasingly responsible for their own tests and procedures. "It sounds scary but it's happening and should continue to happen," she says.
Patients have proven they are capable of tending to their own health issues: Diabetics manage to measure their insulin levels and women take pregnancy tests at home all the time.
"Pregnancy tests used to only be administered in the doctor's office. And there was a huge uproar by doctors when they wanted to do over-the-counter pregnancy tests because they didn't think women could handle it on their own."
That trend of passing to patients some of the responsibility for their own care will continue—from ordering lab tests without a permission slip from the doctor to at-home medical devices and technologies such as blood pressure cuffs, glucose meters, and smart scales.
"Why do you need to go through the whole doctor system?" she says.
Although some docs might bristle at the thought of being seen as middle-men to be avoided, Lynn says a more patient-driven healthcare system will ultimately make their lives easier. "The benefit to doctors is that they can practice medicine. Right now there are so many arcane things that happen that they can get closer to the patient, they can practice medicine, and they can do it based on data and results. And that's incredibly powerful."
So why should it fall to outsiders to reinvent healthcare? Because they "don't know where the walls are," she says. They have a clearer vision of what works in other industries and tend to be more consumer-focused than providers, she adds.
"They don't have an entrenched interest," she says. "There's been a ton of resistance from the industry because they want to preserve the status quo. And that's typical of any industry that's about ready to be changed and reinvented."
Meanwhile, if healthcare needs outside help in order to change, it can also help the outsiders who are trying to change it, Lynn says. Healthcare organizations should have a process for investigating start-ups—an innovation committee, if you will. Entrepreneurs need a contact point with people who understand the organization's needs and have the authority to run a pilot and approve promising new technologies more rapidly.
"We can't afford the healthcare industry as it stands. The healthcare industry is—I won't even say probably—it is the most inefficient, unbelievably cumbersome industry that you could imagine," she says. "You [have to] look at ways to deliver better care to patients, increase efficacy, reduce readmissions, and reduce cost. And that is why [healthcare] has to be reinvented."
This article appears in the December 2011 issue of HealthLeaders magazine.
Healthcare organizations are working to encourage patients to get engaged in their healthcare data, in part by making Personal Health Records more user-friendly. Part of the adoption problem isn't just a lack of consumer awareness, but the fact that many physicians are wary of records that are created and controlled by patients.
Among their concerns: time, accuracy, and control over data.
1.Time
Physicians who are reluctant to participate in the PHR system at the University of Pittsburgh Medical Center most fear that having a direct connection between themselves and their patients would take too much time, Daniel Martich, MD, chief medical information officer and vice president for physician services at UPMC, tells HealthLeaders Media.
UPMC uses a PHR system called HealthTrak, a Web-based portal that allows patients at its 20 hospitals and 400 outpatient sites to feed data into the electronic record. More than 70,000 patients currently use the system.
"They worried that the patient would write tomes, as opposed to a quick phone conversation. They thought it would be so onerous, looking at attachments of articles the patient clipped from Reader's Digest and they'd never get through their day," Martich says. "That, by and large, is myth. In fact, we're finding that patients are much more succinct if they have to type it in rather than talking to you on the phone."
You could tell docs that they're over-reacting. But it's better to offer them data.
Holly Miller, MD, chief medical officer with Fishkill, NY–based Med-Allies and a HIMSS director says she participated in a Cleveland Clinic study that showed physicians actually saved time by allowing lab results to be released to the PHR rather than calling the patient.
2.Data Integrity Reliability of the information in the PHR is key, Miller said. Early experiences with PHR models have shown that physicians will not trust any model that depends on the patient entering data. It is far too easy to enter incorrect or incomplete data, she says.
Physician adoption also depends on the PHR being automatically generated through the EMR, she says. "It is unrealistic to expect a provider to go outside of their work flow and log in to a disparate system," Miller said.
3. Loss of Control Over Data Docs are certainly justified in their concerns about data accuracy, but there's also a more subtle fear that they will lose control over the data. They don't like the idea of patients getting instant access to lab results without first talking to a doctor, for example.
(A rule proposed this past fall by The Centers for Medicare & Medicaid Service and two other federal agencies would amend the Clinical Laboratory Improvement Amendments of 1988 (CLIA) and require labs to release results directly to patients or their designated representatives upon request.)
"They're worried that the patient is going to get horrific news without the doctor first being able to review it, refine it, and present it in the best way," Martich says. "That concern is understandable, but it really has not been a problem."
But even benign results can be hard for the layperson to interpret.
"A number without a contextual relationship and without some level of interpretation is totally worthless …Relaying data to a patient is totally unrelated to relaying information to a patient," Bernard Emkes, MD, medical director managed care services at St Vincent Health in Indianapolis, said in a recent interview about the proposed CLIA rule. "Data is 'Your A1C level is 11.' Information is 'Your A1C level is 11 and oh my God we've got to get on this right now and here's what we need to do.'"
Most agree that patients need help interpreting and understanding lab results—however those results are delivered. One solution is to include an explanation of any test results delivered via a PHR or other direct-to-patient means and include links to more detailed information.
The CLIA rule would make patients more involved in their own care, said Alice Leiter, director of health IT policy at the National Partnership for Women & Families, in a recent interview. It would allow patients to "loop back around to their care team so that patients and providers can work together on how to interpret and understand lab results."
Healthcare leaders say they're struggling to cut costs and waste in the emergency and surgery departments. But some say the real savings are to be found through technology and the use of business intelligence.
In a recent intelligence report from HealthLeaders Media, Cost Containment Under Healthcare Rules, healthcare leaders said eliminating excess cost and waste is a top priority, but added that progress is difficult to achieve, especially within the ED and surgical services, where 65% and 48%, respectively, said it is very or moderately difficult.
They also said information technology is part of the solution.
"Operating room information management technology is one of few areas in the hospital that stands to benefit substantially from a financial standpoint with a solid return on investment in IT," said one survey respondent, the chief of staff for a small hospital. "Unlike other areas of the hospital, the operating room is most akin to a factory production line, and has the most to gain from IT implementation."
But they survey results suggest respondents lack the tools they need to reap those benefits. We asked leaders to describe how their organizations currently use information technology to guide cost efficiency programs.
Only 16% said they "have robust clinical and financial data integrated with solid business intelligence and analytical tools" to guide them. Another 67% said they have "some reliable clinical and financial data" that they use to achieve results. And 17% said they currently lack clinical and financial data for improvement.
In a roundtable discussion, healthcare executives talked about how organizations can use data to get results. Jeffrey Limbocker, chief financial officer at Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, said such data can be used to measure the impact of cost containment.
"Much of the data, even on the clinical side, that we rely on is often charge-based data, and so a charge entry has to take place and then someone will pull data and rely on it, which creates obvious problems," Limbocker said. "The clinical data that many of us also use consists of chart reviews. Chart reviews are still a fairly standard way to review data as opposed to having a clinical data field in a clinical information system. What you want to do is be able to compare high-quality outcomes with financial outcomes so you can see whether the things you're doing to improve clinical quality or reduce cost are having a positive or negative impact on the other."
And yet, noted roundtable moderator Philip Betbeze, senior leadership editor for HealthLeaders Media, it is difficult to determine the true cost of providing a service and the testing, labor costs, and other costs because there are so many variables involved. "How do you begin to make sense of it?" he asked.
Charles E. Hart, MD, president and CEO of Regional Health, Inc., in Rapid City, SD, agreed it's a problem. "I just wish I knew for sure the cost to provide a service. Revenue is a little bit easier. That's dollars in the bank," he said.
"Business intelligence is defined differently by different people, but to me it's being able to put together three or four source data systems in our institutions where data from all the platforms can be seen together in a succinct format," Limbocker said. "About 10 years ago, I was very proud of creating a senior-level dashboard and departmental dashboard for all leaders across the institution, where before they were getting a stack of paper several inches thick. Well, it was still too much data for most."
The key is to determine what kind of data is really actionable, said Paul Kronenberg, MD, CEO of Crouse Hospital in Syracuse, NY. "People say information technology will give you accuracy, but it won't necessarily because something has to be entered by a person. So just because it's electronic doesn't mean it's accurate," he added.
There are some "excellent" business intelligence systems available to the healthcare industry now, said Barry Waiter, vice president of OptumInsight in Pittsburgh, PA, which sponsored the Intelligence Report. These systems enable exception reporting that allow users to start with high-level metrics and then drill down to a granular level to understand the drivers of variances. "Hopefully managers and executives will get more comfortable with business intelligence systems over time," he said.
I would have finished writing this column much earlier if I hadn't gone online to do a little first-hand research and clicked on an online personal wellness game created by Hartford, CT-based health insurer Aetna in partnership with Seattle-based social media company Mindbloom.
I have to admit I spent a little bit longer on the site than I probably should have been during work hours.
Then again, that's the whole idea.
The platform takes advantage of the science behind social gaming and blends technology, art, and behavioral psychology to engage users in achieving personal health and wellness goals, according to the two companies.
"I'm very passionate about personal development," Mindbloom co-founder Chris Hewett said in an interview. "I'm a big believer in small steps every day and the key is every day. So how do you get someone to change their life one small step at a time? It's about engagement. The idea was to tap into game elements, inspirational content, and social to make this a very powerful way for people to grow the life they want."
The site relies in part on gamification to increase and sustain engagement. Each user has his or her own tree with leaves that represent different areas of life, including health, finances, and spirituality.
Users keep the tree healthy by scheduling and performing tasks. So, for example, one of my goals is to drink more water. When I meet that goal I'll earn sunshine and water to keep my tree healthy. If I don't, my tree will wither and die.
I can add inspirational quotes, personal photos, and music. And I can invite friends to join and share my progress on the site or via other social media sites such as Facebook.
When you set goals, accomplish tasks, and perform other actions, your tree produces seeds that can be used to send a little burst of rain to a friend (200 seeds per shower) or to upload 50 additional images (1,000 seeds per upgrade), for example.
Getting patients engaged in managing their own health is a growing priority in the industry. The trick is how to accomplish that. Some suggest that the only way to get patients to do anything is to gives them incentives or disincentives, from virtual raindrops and sunshine or cold hard cash to higher health insurance deductibles for those who fail to improve their health.
"We support the use of financial incentives today for engagement," said Dan Brostek, Aetna's head of member and consumer engagement. "There's this big discussion around real versus virtual rewards and which one works or if it's a hybrid that will work. I'm a believer that the financial and tangible rewards will get people there and get them to participate initially. But if you want sustained engagement around true behavior change it has to be intrinsic. And that's where emotional rewards come in—things you can't touch but you can feel."
"This, really, to me is about creating a vision of why I want to be healthy. It's not about getting a five-dollar discount at some local sandwich shop because I met my health goals today. It's about 'I want to be healthy because I want to be with my kids,'" Hewett said.
"The financial, the tangibles will get people there. It's a good way to market and communicate the capability of the experience. But then to keep them there, which is what we're all after, it's got to be more emotional in nature," Brostek said.
And fun.
"We did a ton of quantitative and qualitative research and what came back was [that users] want fun, easy, rewarding, and social. It's going to be critical for us that the next layer takes into account the new features and functionality and then what we can start to incorporate into the user experience moving forward across those different distribution channels," Brostek said.
"We want this thing to be part of people's lives. Because you're going to invest a lot into it—putting your images and you music and your quotes and your journal entries. And it really is touching on all aspects of your life," Hewett said. "It's got to be focused on outcomes, behavior change, and it's got to be cool and interesting and engaging and leverage some of the consumerism trends right now for it to work."
Initial numbers suggest the companies are meeting the goal of sustained engagement: 15,000 beta testers visited the site an average of 3.5 times a week and spent about 15 minutes on the site. In all, they scheduled 1.3 million daily intentions or tasks (such as drinking more water) and 75% of those tasks were completed. The average user stayed on the site for about 16 weeks after he or she first registered.
Aetna is pleased with those stats and recently released a suite of new features it hopes will keep users around even longer. One of them is custom content. Aetna can populate its customers' sites with articles about certain health topics, for example. Large employers, hospitals and health systems, or other sponsor organizations can also offer content such as articles and videos for their target audiences.
"We're thinking about it as a wellness [program] that could be distributed through our large B2B relationships. But at the same time we're also thinking about it as a consumer-oriented platform. Because that's how we started this concept inside Aetna before we ever partnered with MindBloom. It was all about creating a consumer oriented experience," Brostek said.
"The interesting thing with solutions like this, interactive health [and] broader well-being solutions, is there's a fine line between individuals as users and what they want from the experience and what a sponsor or carrier may want or even healthcare professionals. How do you walk that fine line so they don't feel like they're in their insurance company's back yard or their employer's back yard? They actually feel like they're in a very immersive, safe environment where they can share to the extent that they want to share with colleagues, friends, family," Brostek said.
In last week's column, I wrote that healthcare information technology professionals who identify themselves as healthcare workers?as opposed to HIT workers?might be happier and more effective in their jobs.
This week I have a Q&A with Sheila Currans, CEO of the 61-bed Harrison Memorial Hospital in East Cynthiana, KY. Currans talks about the CIO's role in the C-suite, and how IT professionals can better communicate with others in the hospital, contribute to their organization's mission and strategy, and improve patient care.
HealthLeaders Media: In your organization, the CIO reports directly to you. What's the reasoning behind that?
Sheila Currans: We moved the CIO into that senior leadership [position] about eight years ago because we had so much coming down the road. It's just so much simpler if I can understand it all from the ground up. The CIO is part of the senior leadership. We meet regularly, and our meetings are primarily focused on our strategic planning for the care of the patient?not IT. CIOs should start thinking about how they support the mission. We've done that for several years and it's worked well.
IT is relatively new to the leadership arena. We're all used to the chief financial officer or the chief nursing officer. But the CIO is relatively a new position. And, unfortunately, I think too often it's been relegated to a basement support service. Today's world puts IT as an integral part of healthcare. It's going to touch everything that happens for the patient.
HLM: Why do IT professionals, in particular, have trouble communicating with other leaders?
SC: I've been accused of speaking with too many acronyms, abbreviations, and technical language. IT folks have their list of acronyms just like a lot of other folks do. But theirs seem very technical. They can get frustrated when people don't understand them. It's important to help them understand that you have to send a message to people and they have to hear it and understand it. They've got to communicate the same language that the rest of the hospital or the health system communicates.
HLM: How can IT professionals do a better job of communicating with clinicians?
SC: CIOs think they're under a lot of pressure?and they are?with all of these new standards. As we've prepared for stage one of meaningful use, we've had to implement additional prompts that the physicians have to respond to. The CIO has to fully appreciate the physicians' workflow. Providers are busy. They see more patients with more complex problems and they cannot be frustrated with what they see as minutia that doesn't add value to the care.
CIOs should think through the process to the end user and show them how it is valuable to them, [and] how it impacts the care of the patient. If you've developed that right relationship with those care providers, they'll go along with you a little bit. They'll give you a little flexibility.
With IT, the one thing I've learned [is that] it's a journey and you're always hearing that in the next upgrade it will be an improved process for that end user. There are constant changes for the end user. All I'm asking the CIO to do is work and think that through as a process workflow before you put the fix in or before you go to the docs and ask them to make a change. Be prepared and appreciate their position.
HLM: What role does IT play in caring for patients?
SC: At the end of the day we're a hospital. We take care of patients. IT is the bridge that supports that core business. Whether or not health IT folks believe it, the healthcare world does not revolve around the computer. It's about taking care of the healthcare needs of our community. And the computer is a resource that we use to help that.
IT folks should see themselves as a bridge between that technical and that touch and learn to communicate. If they do, they'll have a whole new level of reward from the job that they're doing. Because they'll see how it touches the patient and the care.
HLM: How do you encourage IT professionals to engage in patient care at Harrison?
SC: The IT staff round every morning at the same time that the physicians are rounding. Every day, IT is on the medical floors. That's their first priority of the morning is to be available to all of the caregivers as the shifts are changing. That has really helped them to see, quite honestly, that they are a resource and a tool that helps take care of these folks.
When I talk to our CIO my first question is 'how is this going to affect the patient?' You have to come into the same sphere of conversation. How does it affect the patient? How does this help the doctor take care of the patient? How does this help the nurse take care of the patient? Patient care is the most important thing. Honestly, it's the reason we exist.
Rady Children's Hospital in San Diego is further along in its ICD-10 planning than a lot of other organizations. Even so, says CIO Albert Oriol, they're not yet in view of the finish line. Among the remaining challenges: training coders and physicians on the new system, assembling the right team, and ensuring they have the technology and tools they need to complete the project.
Rady, a 442-bed facility that is California's largest pediatric hospital, got started early on ICD-10, in part, because leaders there realized it was "bigger than a coding project," Oriol said during a recent ICD-10 panel at the College of Healthcare Informatics Executives (CHIME) fall forum. It's so easy to lose focus in the face of other pressing technology projects, such as implementing electronic health records and preparing for meaningful use. It's also easy to put your head in the sand and hope that the government will delay ICD-10. "I just don't see it happening," he said.
Although he's "fairly comfortable taking risks," Oriol wasn't willing to gamble on an ICD-10 reprieve. Consider, he said, that poor ICD-10 preparation could increase your current denial rate by 1% - 3%. He asked the audience: Is that a risk you're willing to take?
There's a lot of apprehension among Rady's coders—and one has already resigned, well ahead of the October 2013 conversion deadline, said Cassi Birnbaum, Rady's director of health information and privacy officer. Conventional wisdom holds that many coders will change jobs or retire before the conversion, which will increase the number of disease and diagnosis codes from the current 15,000 to more than 150,000. Further, the new coding system is much more complicated and nuanced than ICD-9.
But it's not just coding professionals who should be worried. ICD-10 experts say organizations that aren't prepared could face significant increases in accounts receivable, rapid decreases in cash flow, high call volumes because of rejected claims, and risk of increased audits and sanctions.
And exactly how much it will cost to implement ICD-10 still largely unknown. "Pick a number, multiply it by 10, throw it at the wall, and see if it sticks," Oriol said. You can predict staffing needs, but there's no way to tell what impact errors and inefficiencies during the natural learning curve will have. "We have no idea," he said.
Success depends, in large part, on getting the right people to manage the project, the CHIME panelists said. Rady has a steering committee with organization-wide representation, for example. At SSM Healthcare, a 15-hospital system based in St. Louis, health IT and human resources are working together to prepare for training, said project manager Carole McEwan.
One decision both organizations had to make: Should the team that implements ICD-10 be the same group that's working on electronic health records? Here, the two organizations differed in their strategies.
SSM is currently implementing an EHR and many of the same people work on both projects. So the ICD-10 and EHR projects share a steering committee. It's a well-functioning team, McEwan said, so it made sense to build on what was already there.
Rady went with a separate ICD-10 group that also incorporates members of the clinical documentation improvement team. CDI is a foundation for ICD-10 preparation, Birnbaum said. You can't code what you don't document. Bad documentation on the front end pollutes the stream, she added.
McEwan estimates SSM will ultimately provide more than 100,000 hours of training for ICD-10. SSM decided to build its own training system rather than purchase one off the shelf. It will create six classes to deploy throughout the organization.
Physician training is just as important as coder training. "The bottom line is documentation," said Birnbaum.
Rady tested ICD-10 using a full year's worth of ICD-9 coding data, Birnbaum said. Primary care physicians did the same, also mapping out a year's worth of clinical data on their own.
If you're aiming for the October 2013 ICD-10 implementation deadline, you're already too late, the panelists agreed. To be safe, organizations should be ready to go at least six months before that. These projects take time to "ramp up," said McEwan.
"If you're not ready by October 2013, that's an excuse for [payers] not to pay you," Birnbaum said.