What's the difference between healthcare IT professionals and their peers in other industries? Well, the answer might depend on how the healthcare IT professional answers that classic cocktail party question: "So, what do you do for a living?" (See the LinkedIn discussion. )
"What makes the great individuals in IT great? The answer is they don't see themselves in IT," said Craig Schiefelbein on the closing day of the College of Healthcare Information Management Executives fall forum in San Antonio last week. "They're in healthcare."
So, what do you do? Are you in IT (or finance, quality, or marketing, or any other department within a provider organization)? Or are you in healthcare?
The answer, says Schiefelbein, who is the co-founder and CEO of Paragon Development Systems and author of the book "Get Out of IT While You Can," can make a difference in how happy you are. It also impacts a lot of other areas that are important to any organization, but critical in healthcare, from patient experience to quality to long-term sustainable growth.
It's so easy to bend your head down and get lost in the day-to-day to-do list. And there are a lot of things to do on the IT department's list these days—little things like implementing electronic medical records and preparing for ICD-10 coding changes, for example.
When you have a chance to look up, chances are you're sitting in yet another meeting room looking at yet another PowerPoint presentation.
In fact, as Schiefelbein pointed out (and a show of hands from the audience confirmed) IT is often housed away from patients. Although it has moved up from the basement, it has also moved out to administrative buildings or wings.
IT needs to get back into the hospital, he said, shadowing clinicians and workers in a variety of departments. In some organizations I've talked to, workers from IT and other departments participate in rounds in order to bring those non-patient facing departments face-to-face with the sole reason the healthcare organization exists.
Schiefelbein also encouraged IT leaders—even those who consider themselves over-achievers—to reach beyond their comfort zone. Both the IT team and the department as a whole must be much more strategic, and focused on business, mission, and customers—especially patients.
Long-term sustainable growth comes from physician and patient loyalty, he added, and those are most impacted by experience.
"If you want to move to the next level, you can't just be the best you can be; you have to be the best in your industry," he said.
For example, he said, many IT departments are focused on coming up with programs that help reduce costs, which is critical. But to truly be strategic, they must also think about how to apply those cost-reductions in strategic ways.
People can go through their entire careers without ever contributing a strategic idea, he said.
Here's a quick litmus test to see if you and your staff are strategic: Imagine that the CEO has a meeting with key stakeholders and asks someone from the department to step in and explain the organization's objectives and strategies for long-term growth, talk about how it will ensure the best possible patient experience, and describe its core competencies.
Could you? Could your IT staff?
And what do you do for a living? I'd like to hear from you: Join our discussion on LinkedIn to answer the question and let us know if you think the answer makes a difference in your organization.
Patient navigation is a growing trend, but Presbyterian Healthcare Services in Albuquerque, NM, is putting its own spin on the service, supplementing in-person consultations with two-way video chat.
And while healthcare organizations are increasingly using patient navigators to shepherd patients through the care continuum, Presbyterian is using it to divert non-emergent patients from the ED, help them find a primary care physician if they do not have one, make primary care appointments for patients, and educate them about ED utilization.
The goal is not only to reduce ED costs—the organization forecasts a savings of as much as $15 million over five years—but to change patient behavior, educating them on when, where, and how to obtain appropriate healthcare services.
Navigation improves access to care and overall quality of care, John D. Johnson, enterprise director of the customer service center at Presbyterian, said during a session at the College of Healthcare Informatics Executives CIO forum in San Antonio last week.
Under the program, patients presenting at the ED get a medical screening by a mid-level provider. Non-emergent patients are referred to the navigator, who helps them with insurance questions and can either refer them to an urgent care center or get them an appointment with a primary care physician within 12-24 hours. Navigators also follow up to ensure the patient has kept the appointment.
Marketing and communications was part of the strategy—in addition to local media efforts, Presbyterian reached out to physicians, leaders, past ED patients, and other healthcare organizations in the region.
There were barriers, especially when it came to physicians, Pete Shelkin, Presbyterian's vice president and CTO, said. Many were concerned that patients would fall through the cracks and didn't trust that patients would get an appointment with a PCP in a timely manner. There is a perception of EDs as a safety net, he added, and providers do not want to turn anyone away.
"It's one thing to get everybody to agree [to] change culture, it's another to get everybody to agree how to do it," he said.
The organization responded with a guarantee that patients would get an appointment in 12 to 24 hours or would be diverted to urgent care if that was not possible. It also spent lots of time and effort on risk analysis and scenario planning. Physicians contributed to establishing the criteria for which patients would be served by the navigation program.
Now "providers love this program," Johnson says. That's because they want to help their patients navigate the system, understand their insurance benefits and get access to and feel comfortable with visiting primary care physicians.
In the first 47 weeks of the program, 10% of overall ED visits were navigated; an average of 23 patients per day across the two EDs that were live at the time.
More than 10,000 patients have received navigation services to date. Presbyterian reduced its left-without-being-seen rate from 15% to 4.5%. And just 4.4% of patients who went through the navigation process have returned to the ED for non-emergent care.
The number who were admitted as inpatients within 72 hours of navigation was 0.3% compared to 6% for overall ED patients; 2.7% of navigated patients compared to 3.6% for overall ED returned to the ED within 72 hours.
The organization also monitors whether patients are seen in the referred location; 79% of patients are seen by a primary care or urgent care provider.
Although the organization knew patient navigation was a good program for their large, urban hospitals, leaders also knew they could not afford to do it in all of their locations. Teleconferencing technology helped to overcome that challenge.
Two-way video chats between patient and navigator were more effective than a phone call because speaking face-to-face—even on a video screen—helps build a connection. It allows tele-navigators to read subtle body language and facial expressions, for example. And, Johnson added, patients actually like the novelty of the technology.
Innovation and change were common themes at this year's College of Healthcare Information Management Executives annual forum—from the challenge of working in a disruption-averse industry to the changes that healthcare will face in coming years, whether healthcare leaders want to face it or not.
The U.S. must move toward lower-cost caregivers and venues of care, said keynote speaker Clayton Christensen. To do so, disparate groups must overcome their reluctance to collaborate and share power to adopt changes that make common sense, would make care more convenient, and save money.
For example, he said, nurse practitioners could play a bigger role in administering colonoscopies, but physicians object. Meanwhile, physicians say they could do colonoscopies in their own offices, but hospitals object.
Christensen, a Harvard business professor and author, also said that current care delivery must be revamped. Too many healthcare organizations try to do everything for everybody—an inefficient and expensive model.
He cited as an example two manufacturing plants. The first organized its workflow around its expensive equipment and machinery. The plant could make any piece of equipment, but the steps to do so were constrained by the layout of the machines, resulting in a work process with many steps and an inefficient, multi-step, multi-directional workflow.
The second plant decided to focus on manufacturing specific pieces of equipment that worked with the plant's linear pathway. The second plant could not do everything for everyone, but it could do jobs that fit its schematic with higher quality and lower costs in less time than the first plant.
Most hospitals are set up like the first plant when they should be set up like the second, Christensen believes. The average hospital has 110 different pathways. And while we do need general hospitals, we just don't need quite so many, he said.
The second manufacturing plant is a model for what Christensen calls a "solution shop hospital." This type of healthcare facility identifies specific problems and finds and recommends solutions. National Jewish Health in Denver, a respiratory hospital, is one example of the solution shop hospital. A patient flies in and four pulmonary and respiratory disorder specialists come into his or her room, ask questions, argue with each other, look at the data, do some tests, and come to an agreement about the diagnosis and recommended treatment plan.
Even considering that the patient flew to the facility and spent 30 minutes with four different doctors, comparatively speaking the encounter was "dirt cheap," Christensen said. "A precise diagnosis is worth its weight in gold … and it will save money down the line in care."
Passion and dispassion
Innovation and change were also themes of Michael Leavitt's keynote address. Leavitt, who served as governor of Utah and as secretary of Health and Human Services, said the healthcare industry has always been driven by compassion. That is part of the American ethos, he said.
In the next five years, however, there will be a new force shaping healthcare: global economic dispassion. Financial reality will force healthcare to do a better job of finding greater efficiency through collaboration and networks such as accountable care models. Otherwise, compassion runs the risk of being run over by dispassionately demanding creditors, Leavitt warns.
Like Christensen, he suggested that having general-service hospitals on every corner is not a sustainable model. Having fewer hospitals is not dispassionate, he said, but economic reality.
So what is the role of innovation in this new healthcare landscape?
In the past, healthcare innovation meant inventing a new device or finding a new treatment protocol. There is now a new category of innovation, Leavitt said, and it's all about finding, defining, and demonstrating value. "The future will belong to the people who innovate in that space," he said, and will define healthcare organization's ability to succeed.
Those organizations that resist innovation will fall victim to economic dispassion. Healthcare organizations have three choices, he said: fight innovation and die; accept it and chance to survive; or lead it and prosper.
Six Steps to Innovation
Innovation doesn't just happen—it requires an idea-to-execution process, says Ed Marx, senior vice president and CIO of Texas Health Resources. Done right, innovation can play a role in both developing and supporting the business strategy and can improve clinical and business outcomes.
Marx, offered the audience at the CHIME meeting advice for nurturing and sustaining innovation:
Invest in innovation. It doesn't take magic to innovate—just money, people, and time. Provide clear support from senior leaders, encourage innovation among all employees, give employees time to think, and encourage collaboration.
Build an innovation process. Create and define a process for innovation, focus on continuous improvement, and set up program management. Throughout the design, think about the customer's experience and ideas.
Hire for innovation. Don't hire people just like you, Marx said. Rather, hire creative types—even people who make you feel uncomfortable or who are noncomformist. "I don't care what people wear," Marx said.
Manage innovation killers. Folks who say they are "just playing devil's advocate" are often really just trampling on an idea. Don't tolerate it.
Embrace failure. Non-clinical failures are a good opportunity to learn. Good leaders understand that, Marx said, and resist "destructive criticism."
Lead innovation. Leaders should operate with humility but also with courage. "I'm not afraid to take on anyone in the organization," he said. "And I protect my people."
The innovative attitude at Texas Health Resources has resulted in several unique technology programs. Among them:
Personal health devices to monitor patients and keep them out of the hospital, including blood pressure cuffs and personal EKG devices.
A "Connecting Babies" program that allows parents to check on their infants in neonatal intensive care units via video. It includes a social media element that lets parents and caregivers interact.
A venous thromboembolism calculator that alerts physicians when a patient is at risk for a VTE and automates the calculation process that docs use to create orders, replacing the old paper-based system. Since introducing the app, VTEs are down 20%, Marx said, and the process takes about half the time.
"When you innovate, you save people's lives," Marx said. "If you don't innovate you will perish."
A successful connected health program, in which patients use information, technology, and other tools to engage in their own care and self-manage conditions such as heart disease and diabetes, involves a lot of preparation. In fact, the planning for a connected health program begins well before you even launch a pilot program.
Any kind of change will be resisted by an equal, opposing force, observes Susan Lane, RN, corporate manager of technology and operations for the Partners Center for Connected Health (PCCH), which hosted its annual symposium in Boston last week. To create a program that can grow, you must have a clear focus and put measurements in place that will translate to a final scaled program if the pilot is successful, she said.
Connected health programs use technology to deliver care outside of the provider setting. For example, a program might connect patients and physicians via remote monitoring and e-visits and allow patients to upload their own data and track it online. The technologies and tools track medication adherence, weight, blood pressure, and other vital signs.
The goal of these programs is not only to get patients more involved in their own health, but also to give physicians and caregivers early warnings and a chance to intervene when a patient's health is declining, in order to avoid readmissions and trips to the emergency room.
Lane and four other members of the PCCH team outlined six steps taao creating a successful connected health program:
1. Create objectives and a justification
A connected health program typically starts off with a pilot, says Khinlei Myint-U, corporate manager for product development and communications at PCCH. But one step that's sometimes overlooked is setting a focus and a goal for the pilot. For example, a feasibility pilot would look at the impact on workflow and how the program affects the patient, while a research pilot would examine outcomes and utilization. Whatever type of pilot you're considering, be mindful of what you want to learn from the outset, she says, and create specific learning objectives that are defined in the very first stages of the project.
Another piece of advice from Myint-U: Even if leaders don't ask, include a financial ROI measurement. Identify the drivers of costs and benefits not only for the pilot, but also for the final scaled program. Of course, as payment models change so will the value equation, so be prepared to revise your numbers.
2. Design the program
One of the reasons to create objectives and build a justification for your project is to get stakeholders on board. Be very clear about those objectives, Myint-U advises.
In designing a program there are several questions to ask: Who will the program target, and how will you find and enroll patients? How do you relay the expectations to the patients? What is the role of clinicians? What data will you collect and who will monitor it?
3. Choose technologies and operational processes
A big challenge in choosing a vendor to help build the connected health program is that the concept—and the technology to support it—is so new, says Rob Havasy, project specialist and operations manager at PCCH. Investments in new technologies and adapting existing technology to support your connected health program is not inexpensive. Further, you must test your capabilities with an eye toward the final scaled project in mind. "We don't want to just run pilots," he says. "We want to change healthcare."
One of the biggest operational challenges is physicians who are reluctant to turn patients over to the IT department or an outside vendor. Doctors want to protect their relationships with their patients. Be prepared to offer above-average support to both physicians and their patients. Help desk staff should be well-educated, highly compassionate, and well-paid, Havasy says.
4. Build adoption and engagement
Lane notes that organizations need two people, in particular, to overcome resistance and ensure success of a connected health program. The first is an executive champion—the highest-level person who can override "no" and authorize resources, money, and time as well as approve the pilot. The second, and equally important, person is an administrative champion, the "feet-on-the-street and make-it-happen" person. He or she will make sure the program has the right staff and technology and ensure successful project management.
In a connected health model, there are lots of end-users, including patients, caregivers, doctors, nurses, and social workers, says Alex Pelletier, PCCH's corporate team leader. Each of these groups has different needs and will require different adoption and engagement strategies.
The newness of connected health can make it tricky for end-users, especially patients. In a typical connected health program, 60% of patients might engage—sending in their reading daily, for example. So how do you reach the other 40%. "I don't think we have all the answers to all of this," Pelletier says.
Nudges and incentives can help improve patient engagement. Those might include automated reminders, such as text messages or emails and reminders and outreach from family members and providers. But none of these tactics will work all of the time for every patient, Pelletier says.
For providers, the key is to make life as easy as possible, he says. Recruit champions and influencers first—those who are willing to try something new, share what they learned with their larger circle of peers, and convince others that connected health is the right thing to do.
Maintaining engagement is another challenge. Clearly communicating program goals and what each user must do to accomplish them can help, Pelletier says. Define what a healthy program looks like and watch the data to ensure you're on the right track.
5. Evaluate your efforts
If you evaluate your program when the pilot is complete, you're too late, says Kamal Jethwani, MD, lead research scientist at PCCH. You must build in evaluation during the program design phase. For example, if you determine during program design that you will focus on patients who are most at-risk for readmission, later on you can measure whether you reached the appropriate audience. And if you decided your pilot would focus on improving outcomes for patients, you can measure readmissions and utilization throughout the program pilot and figure out if you asked "too much or too little," he says.
You should also be measuring the effectiveness of individual program components, such as the impact of nudges and incentives on adoption. When assessing patient engagement, look not only at the number of patients who signed up for the program and reported in at least once, but also how many patients continued to participate.
Armed with that data, Jethwani says, you can figure out the difference between engaged patients and practices and those who were not engaged, with an eye toward future improvements. Other questions to ask: How did patient and practice engagement correlate and how did the program affect patient and provider satisfaction?
6. Start all over again.
Answering these kinds of evaluation questions is not the end of the process for connected health programs, Jethwani says. You will make more changes based on your evaluations, perhaps even changing your goals and objectives. "Be open to that," he says, and to the cycle of connected health.
One of my favorite quotes from last week's Center for Connected Health Symposium in Boston came from Peter Tipett, MD: "Information technology can reduce cost, increase quality, and advance science," said the vice president of industry solutions and security practices at Verizon's business unit. "But other than that it's not worth it."
In so many ways, so many kinds of Health IT make perfect logical sense. Making patient medical records easily accessible in electronic format? A no-brainer. Giving patients access to their own records which, after all, belong to them? Makes sense. Tools that help clinicians make quick and accurate evidence-based diagnoses at the point of care? Well, of course that's a good idea.
Another of my favorite nuggets from the symposium was when Joseph Kvedar, MD, founder and director of the Center for Connected Health, said researchers add that line to the end of their papers because it's in their best interest—they are, after all, in the business of conducting said research.
Tippet noted that it's not just a healthcare thing—there's very little science about the efficacy of technology in any field. Did Watt need empirical evidence before patenting the steam engine? Did Sony do double blind studies to see if consumers would rather listen to music on a Walkman instead of lugging a boombox around on their shoulders? Did the healthcare industry need peer reviewed studies of imaging technology such as CT-scanners when they were new?
Oh, wait. Scratch that last example.
OK, so there are some healthcare technologies that demand rigorous study. But do text messages reminding patients to take their medication at the correct time each day fall into the same category? What about wireless scales that send a patients' weight to their doctor's office? An app that helps overweight patients make healthy food choices or gives tips to folks trying to quit smoking?
Again, back to the symposium. In a debate-style session, Kvedar and Sahid Shah, CEO of the health IT consultancy Netspective who blogs under the handle The Healthcare IT Guy, debated whether current approaches to patient self-management improve quality or lower healthcare costs.
Much of their back-and-forth focused on evidence (or lack thereof). Kvedar cited several examples of how his organization and other researchers have shown that tech-enabled patient programs can improve outcomes. "There's plenty of evidence," he said.
But Shah argued there's a need for concrete evidence from large-scale studies for any technology that is prescribed by a physician to a patient regardless of how that technology is used—even if common sense says the technology could help the patient.
Shah noted that although the airline industry lets customers make their own travel arrangements by booking their flights online and checking in at airport kiosks, it hasn't made air travel safer or less expensive.
But there's a flaw in that argument. The airlines didn't make those changes to help consumers save time and money—they did it to save themselves time and money. And they certainly didn't do it to improve flyer safety.
But what if you gave every airline passenger a breathalyzer kit they could use to ensure the pilot is not drunk? Or sent them a text reminding them to buckle their seatbelt before takeoff? Or gave them an app to remind them how to put on a life vest in an emergency? Would those things improve the quality and safety of passengers?
Frankly I have no idea.
But how on earth could it hurt?
To be fair, Shah was asked to argue that self-management doesn't improve patient safety and quality or reduce costs—the whole premise of the session was to engage in debate. In any other situation, he said, he'd probably concur with Kvedar.
Good. But I wonder about the bulk of the medical profession and whether they're ready to cede even a little bit of control to patients—and the technology that can help them manage their care outside the doctor's office.
The correlation between accountable care models and healthcare information technology that connects and engages patients permeated conversations at The Center for Connected Health annual symposium in Boston last week.
As news of the final rules broke, participants weighed the importance of electronic health records in a successful ACO business model. And panelists at two sessions discussed accountable care's merits and pitfalls, touted the model's potential to make healthcare more connected and participatory, and warned that many barriers still stand in the way to patient engagement.
Midday Thursday, the first day of the conference, came word that the federal government had released final ACO regulations with major concessions to the original plan. One of the critical changes: The rule no longer requires that 50% of participating physicians be meaningful users of electronic health records.
Some at the symposium reacted to that news with a shrug.
"I don't necessarily think that's a bad idea because I can't imagine anyone [creating an accountable care organization] without an EHR," Joseph Kvedar, MD, founder and director of the Center for Connected Health, said in an interview.
"What's being required of us to be an accountable care organization is a tremendous level of coordination. And God knows we'll need many more technologies than just EMRs. That's the baseline. So in a way it makes sense for them not to have to prescribe that. If we're stupid enough to try without it, then let the chips fall where they may."
Daniel Sands, MD, agreed. "Any organization that's not using an EHR—they're not going to make it as an ACO. It's going to be hard enough for organizations that do have computerized data to be ACOs and not go under in the first three years," said Sands, a physician at Beth Israel Deaconess Medical Center and senior medical informatics director at Cisco Systems who was also attending the symposium.
Other legislation, including meaningful use regulations under the HITECH, will incent organizations to use electronic health records, said Sands, an advocate for connected, participatory medicine and one of HealthLeaders Media's "20 people making healthcare better" in 2009. "It may be necessary, but not sufficient for ACOs to be successful. But the government shouldn't be deciding that."
The Centers for Medicare & Medicaid Services did retain the use of EHRs as one of 33 quality measures (reduced from the original 65). EHR use, in fact, will be given more weight than the other 32 measures.
Regardless of the final mechanics of accountable care, hospitals adopting the model will still need to engage their patients in order to get the better outcomes that are required for success, Kvedar said.
Not everyone at the conference was rosy on accountable care. Among the concerns: differentiating between the capitated model of the 1990s.
Timothy Ferris, MD, medical director of the Mass General Physicians Organization and a senior scientist at Partners/MGH Institute for Health Policy, was an internist in the 90s. Fifty percent of patients at the time felt the managed care model was hurting them—whether or not they were in managed care programs, he said.
Physicians' dissatisfaction about managed care was contagious—and patient perception that the healthcare system was stinting on their care contributed to its downfall, he added.
Managing patients' and physicians' expectations and better educating them about the differences between managed care and accountable care—such as the increased emphasis on quality of care, for example—could help the new model avoid the same fate, said Jonathan Gruber, PhD, a professor of economics at the Massachusetts Institute of Technology.
Dana Safran, senior vice president of Blue Cross Blue Shield Massachusetts, agreed, saying healthcare organizations must frame the discussion in terms of accountability for both cost and quality. Outcomes are the counterbalance that was lacking in managed care.
"The question is [whether it will] be enough from the perspective of the patient," she said. "There's a lot of room to do this injudiciously in terms of incentives."
The biggest challenge facing accountable care, Safran said, is the fragmentation, chaos, and lack of communication that plaques the industry. That will affect whether patients successfully self-manage their care after leaving the physician's office or hospital or whether lack of understanding and motivation, as well as day to-to-day problems and financial barriers will get in the way.
Healthcare organizations have checked a lot of technologies off their to-do lists. According to the 2011 HealthLeaders Media Industry Survey of technology leaders, most have or are close to implementing wireless networks (95%), computerized physician order entry (91%), clinical data repositories of current data (88%), data mining of historic data (75%), and electronic health records (89%).
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The 2012 industry survey is currently in the field and results will be published early next year. Will healthcare organizations finally catch up in adopting newer technologies? Here's my analysis:
1. Telehealth is Up
In this year's survey, 30% of respondents said remote applications are at least three years out—and 13% said either that they're more than five years out, or that they won't pursue them at all. But over the past year, telemedicine has become more widespread for a few reasons.
Chief among them: Advances in telehealth technology. In the past year, this has meant faster and more reliable networks, wireless devices, high-definition digital images and video, and other functionalities.
And there's been movement on the legislative front, easing some of the concerns that have been holding telemedicine and remote health back. Earlier this year CMS implemented a new credentialing and privileging process for physicians who provide telemedicine services, for example.
Small and rural hospitals are increasingly driving the telehealth boom, banking on e-visits to improve access in areas with physician shortages, for example. In this year's community and rural healthcare leadership survey, 50% said a shortage of primary care physicians will have a negative or strongly negative impact on their organization; 51% said the same in regard to specialists. Some see telehealth as a solution.
Finally, there's a growing recognition that telehealth can aid in monitoring patients after discharge, potentially cutting down on ED visits and readmissions. That will be important as bundled payments move from theory to reality. In this year's CFO survey, finance leaders said bundled payments will have a negative impact on their organization (48%); another 7% said they'll have a strongly negative impact.
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"Prepare now to ensure a smooth transition—don't wait!" exclaims CMS's ICD-10 site. But in the 2011 survey it's clear that the healthcare industry, famous for its "I'll believe it when I see it" approach to preparing for pending regulations, is indeed waiting. In the 2011 survey, only 9% of IT leaders said their organizations are ready for ICD-10. Most (64%) said they'll be ready within one to two years.
CMS's timeline calls for internal ICD-10 testing in January. But the ICD-10 switch is currently set to flip October 1, 2013—a date that must seem very far off to those who are otherwise occupied with more pressing IT projects, such as becoming meaningful users of electronic health systems.
But there's danger in procrastinating when it comes to ICD-10—it has the potential to blow margins to smithereens if not completed on time.
3. Patient Portals Are Flat
The pace at which healthcare organizations have implemented interactive patient portals with advanced features such as appointment scheduling and lab test results has been slow. In this year's survey, only 13% reported having one. And although 48% said they plan to have one in one to two years, 39% said they won't have one for three to five years or more.
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In fact, organizations that have been slow to develop a portal considered advanced by today's standards could find themselves even further behind in 2012 and beyond if predictions about patient portals of the future—ones that integrate social media functions or offer access via mobile devices, for example—come to fruition.
This year's HealthLeaders Media Industry Survey is now live. It's open – but only until Friday – to leaders at hospitals, health systems, and physician practices, including CEOs and other senior administrators, technology, quality, finance, and physician leaders.
So much can go wrong during so-called transitions of care. Lack of communication and coordination with primary care physicians when a patient is discharged from the hospital, for example, can compromise patient safety, lead to ED visits and readmissions, and cause a host of other problems.
So how can health information technology make care transitions safer and more seamless?
That was the question posed at a working meeting of developers, healthcare providers, patient organizations, technology companies, health IT experts, and officials from government agencies in Washington, DC, on Friday. Kaiser Permanente sponsored the event along with the John A. Hartford Foundation and the Gordon and Betty Moore Foundation. Participants worked to identify immediate and short-term technology solutions to improve care transitions and brainstormed new ideas.
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"It is increasingly clear that health information technology, implemented in a patient-centered way, has vast potential to help us reduce the number of injuries, accidents, and re-hospitalizations that are causing stress and harm to patients, particularly older patients, every year," Christopher Langston, PhD, program director of the John A. Hartford Foundation, said in a statement.
Participants cited poor communication and coordination among providers and lack of patient input as the most pressing problems. Among the most promising solutions are more effective risk stratification as well as better use of home monitoring, mobile health, and telehealth and IT systems to allow primary care providers to track their patients along the continuum of care and to facilitate a feedback loop among patients, providers, pharmacists, and others.
In a crowd-sourcing exercise, most participants (58%) agreed that care plans fail to include medical and social factors, fail to coordinate interdisciplinary input (including patient input), do not include processes and milestones, and are not reconciled across time and setting.
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More than 50% said essential care providers often have no input into the transition plan, including the primary care physician, the public health department, family, home health agencies, and pharmaceutical companies.
Among the most promising existing IT solutions, according to the group:
Interoperable information exchange, including clinician and pharmacy data.
Consistent implementation of a proven model of communication among patients and providers.
More effective risk stratification that incorporates both clinical and social factors.
And the group said future innovations should focus on:
Feedback loops to identify when patients do not follow discharge instructions--by filling prescriptions or making follow-up appointments, for example.
Electronic medical records and personal health records that merge medication information, including data from local pharmacies that provide medication therapy management.
Lasting and significant change will require large-scale, systemic change, said George Bo-Linn, MD, chief program officer of the San Francisco Bay Area Program with the Gordon and Betty Moore Foundation. "By expanding the smart use of health information technology during transitions, we are paving the way for smarter, lower-cost health care and new levels of sustainable healthcare quality."
Bo-Linn was one of several leaders at the event who challenged participants to think big. "We're not radical enough," he said during a panel discussion toward the end of the day. "These are great ideas but that's so last Thursday already ... I don't want a plan, I want action."
Many of the solutions to make care transitions safer already exist, he said--and yet even simple solutions aren't implemented. An elderly woman is discharged and her daughter lives nearby but works during the day? Set them up with Skype, he said. Her house has too many stairs, putting her at risk for a fall? Install a motion detector.
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How do you help ensure the health of an 11-year-old asthma patient who is discharged to a household of smokers? Install air quality monitors and give financial incentives to the adults to maintain good air quality. "In fact, you can make it an automatic payment," he said.
And you can monitor how often and when she uses her inhaler; send text medication reminders to her school nurse.
There is a need to identify the "basic stuff that's not happening today, that's killing people because it's not happening," Farzad Mostashari, MD, national coordinator for health IT, told participants. That could be something as simple as ordering discharge wheelchairs in more timely and efficient manners or creating systems to notify a primary care physician when his or her patient is treated in the ED or admitted to the hospital, he said.
Cleveland Clinic's top 10 medical innovations for 2012, released at the annual Medical Innovation Summit last week, included a mix of cool medical devices, new treatment protocols and procedures, and other healthcare technologies that, according to the organization, have significant potential for short-term clinical impact and a high probability of success.
The list includes wearable robotic devices, genetically modified mosquitoes, and medical apps for mobile devices—and one item that's not quite like the others: Harnessing big data to improve healthcare.
"Healthcare data requires advanced technologies to efficiently process it in reasonable time, so organizations can create, collect, search, and share data, while still ensuring privacy," the organization said in a release. "In this way, analytics can be applied to better hospital operations and tracking outcomes for clinical and surgical procedures. It can also be used to benchmark effectiveness-to-cost models."
"Big data"—impossibly large and unwieldy data sets that contain, hidden deep within, a treasure trove of potential for healthcare research and discovery, could have a dramatic impact on efficiency, cost, and quality of healthcare.
A report by the McKinsey Global Institute estimates that better use of big data in healthcare could generate an additional $300 billion in long-term value, with approximately two-thirds of that coming from a direct reduction in national healthcare expenditures.
The federal government, which is the biggest source of big data, is looking for ways to help the industry use data to improve healthcare. Agencies and offices from the White House to the National Institutes of Health to the National Science Foundation to the Department of Health and Human Services to the Office of the National Coordinator for Health IT are partnering with researchers and private IT companies to develop tools to harness big data sets.
NSF has funded several projects focusing on cloud computing to help researchers store, index, search, visualize, and analyze data, "allowing them to discover new patterns and connections," Tom Kalil, Deputy Director for Policy at the Office of Science and Technology Policy, wrote in a recent White House blog post on big data. HHS has spearheaded many projects, including efforts to ease data-sharing among rural healthcare providers.
The healthcare industry is still struggling to get its arms around big data. Analyzing large data sets is not easy. But health leaders can emulate and implement some best practices, the McKinsey report authors write.
The report points to a few healthcare organizations that are doing a good job with big data, including the Department of Veterans Affairs' health information technology and remote patient monitoring programs. "The VA health system generally outperforms the private sector in following recommended processes for patient care, adhering to clinical guidelines, and achieving greater rates of evidence-based drug therapy," McKinsey says. These achievements are largely possible because of the VA’s performance-based accountability framework and disease-management practices enabled by electronic medical records and health IT.
But most hospitals and healthcare systems aren’t ready for big data—not yet, anyway. What's stopping them? Part of the problem is that healthcare data—provider clinical records, payer claims, and pharma research and development, for example—is fragmented. It lies in multiple systems in varied electronic and non-electronic formats and has many owners that often don't share well.
Farzad Mostashari, MD, ONC's national coordinator for health IT, has said repeatedly that the push to get providers to become meaningful users of electronic health records will not only improve quality, patient safety, and care coordination but will also set the groundwork for "massive liberation of patient data."
Patients "have the legal right to access [their] own health information. And that has been the case since HIPAA was written,” he said at a recent ONC town hall event. "The problem is … that’s not always so easy.” Doctors and other providers are "not too thrilled" to share data, in part because they think it will mean more work and in part because providers feel a proprietary ownership of patient data, he said.
It’s “not just a technical problem but a mindset problem,” he said.
Without that massive liberation of data—and a change in attitude about who owns it—big data for healthcare will remain a big missed opportunity.
The federal government will spend nearly $1.4 million to determine "whether and when" providers can share patients' data and to figure out how best to share electronic health data between patients and providers.
In a 36-page document, the Office of the National Coordinators' Office of the Chief Privacy Officer outlines a number of questions and tasks for the contractor, APP Design, Inc., with partnering with providers to creating pilot programs to answering a number of questions about how to engage patients and educate them about their electronic health data.
"The project team will design, develop, and pilot innovative ways to electronically implement existing patient choice policies, while improving business processes for healthcare providers," according to a statement from ONC's Office of the Chief Privacy Officer. The contractor is also charged with looking for an "efficient, effective, and innovative way to help patients better understand their choices regarding whether and when their healthcare provider can share their health information electronically, including sharing it with a health information exchange organization."
The project seeks to:
Establish policies and procedures to guide the consent process
Educate patients about data exchange
Educate providers about their responsibilities with respect to consent management
Develop methods and materials to support the education process
Develop methods and materials to obtain actual consent
Hospitals, health systems, and physician practices are working toward achieving meaningful use by investing in electronic health records and other health information technologies. But one of the "five pillars" of meaningful is to engage patients and their families in electronic health data.
The Stage One requirements of the HITECH Act, already in place, include the relatively simple tasks of sharing discharge instructions and providing patient education. But in future stages providers will be asked to do more -- such as communicating with patients electronically to help them manage chronic conditions and to intervene before they require emergency care.
Last week, Farzad Mostashari, MD, ONC's national coordinator for health information technology conceded that the office has not paid enough attention to patients in developing HIT policies and programs.
The work order is the latest in a series of moves to change that -- and to help providers meet this challenging aspect of meaningful use regulations. ONC has launched a website, healthit.gov, with information about health IT for consumers and healthcare professionals. It also launched a Consumer Health IT Pledge initiative for organizations that participate commit to making it easier for patients to access their personal health data and to educate patients as to why it is important to do so.
The federal government is also putting resources into the Blue Button Initiative, a platform that designed to make it easier for patients to download their medical records.
But there are still a number of challenges, ONC notes, including concerns about privacy and accuracy of the data.
One of the key goals of the Federal Health Information Technology Strategic Plan, published last month, is to inspire consumer trust and confidence in health information technology and electronic health information exchange "by protecting the confidentiality and integrity of health information through appropriate and enforceable federal policies," according to the e-consent work order. "Informed patient choice is one way to ensure a trust relationship with patients for the success of electronic health information exchange."
The "e-consent trial" sets out to answer a number of questions about data-sharing. Among them:
What background information do patients desire and need when making decisions regarding electronically sharing their health information?
Do patients understand the choices they make? How can we determine the level of their understanding?
Are there means of electronically facilitating, obtaining, and recording consent to assist health care providers who are engaged in this process?
There is little research as to whether patients are adequately informed to understand the choices they make with respect to sharing health information, ONC says, while studies show that efforts to collect informed consent for treatment from patients are often inadequate and have little educational value.
"The ability to obtain meaningful consent to share health information presents similar challenges," the document notes.
In addition, too many organizations are still using paper-based consent forms. And even those organizations cited as being ahead of the e-consent curve aren't doing enough, ONC says.
"The efforts by the VA to adopt an electronic consent system are frequently cited, and evaluation to date indicates the value of developing such a system. However, the VA’s system and many other systems in use today are primarily being applied with respect to consent for health procedures or treatment and not for electronic health information exchange. It will be important to address the unique challenges of collecting and tracking patient choice regarding sharing their health information in an electronic environment, where information exchanged between health care providers must indicate a patient’s meaningful, informed choice and enable the patient choice to be honored."