How Healthcare Innovation is Leading to a Post-EHR World

Sutter Health brings Silicon Valley to healthcare IT, to speed up development without an army of IT people. The result is applications that improve care processes and benefit patients.

I bristle when I hear that we live in a "post-EHR world" because, of course, EHRs aren't going anywhere. But in one sense, the moniker is coming true.

That is because EHRs are now exhibiting the classic characteristics of technology platforms: assumed infrastructure that allows anyone, including providers, to innovate on top of them to solve clinical problems, workflow problems, and beyond.

Such is the case at Sutter Health, the Sacramento-based health system serving more than 100 communities in northern California. I recently spoke with Sutter's Kristen Wilson-Jones, chief technical officer of research, development and dissemination (RD&D) operations.

Starting with a technology platform is not the usual springboard for innovation. But if Sutter is any indication, that is changing.

"We have a 'plecosystem'—a platform of ecosystems—that address a lot of the common barriers to innovate in healthcare," Wilson-Jones told me in an interview at the recent HIMSS annual conference in Chicago. Whether by buying or building technologies, Sutter RD&D's role is to pilot and evaluate innovations throughout the health system.

One of Sutter's plecosystem pilots is tackling the effort to lower readmissions rates. Sutter developed a predictive model that generates a list of patients at risk for 30-day readmissions, including demographic data extracted from the Epic EHR, and creates a registry of such patients. Sutter is leveraging Project RED, which stands for Re-Engineered Discharge. Project RED is a research group at Boston Medical Center which develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates.

"It's a pure mashup" of data that creates workflows driven by open-source business process management (BPM) software known as Activiti, Wilson-Jones says. Workflows get prioritized by color—red being tasks that are past due, yellow meaning they are upcoming, and blue meaning they are out in the future.

Tying Activiti and Epic EHR together with other platforms, including Salesforce.com call center automation services, falls upon integration platform technology from MuleSoft that spans application integration, service-oriented automation, and API use cases. It is currently in pilot testing at a Sutter hospital in San Francisco.

Most strikingly, Sutter RD&D built this in six weeks, without the army of professional services resources usually required for such a venture.

From May to December of last year, Sutter saw a 41% reduction in 30-day readmissions in the pilot, Wilson-Jones says.

"A lot of times, it all becomes about the HL7 interfaces" between applications, Wilson-Jones says. "The whole effort becomes about how you get the data between the two systems. We're not moving data around like that. We're a pure API strategy."

App developers such as those at Sutter can think in terms of actual data objects, using APIs to create true mashups between applications. Technology vendors have been promising this approach for years, but until now, it's been beyond the easy reach of developers in healthcare—or, for that matter, in many other industries. That's something to truly get excited about as we look for more rapid, cheaper pathways to innovation in healthcare.

Sutter also is applying the plecosystem approach to other use cases. Its RheumShare application lets rheumatoid arthritis patients report data while in the waiting room preparing for a doctor visit. An on-screen avatar of sorts, which Wilson-Jones laughingly nicknamed "Bone Daddy," lets the patient report severity of pain in various body joints. That data goes into Sutter's information systems in time for the visit in the exam room, where the Epic EHR then places a dynamic hyperlink on those particular patients' screens.

When the physician clicks that link, it launches RheumShare on a second screen installed in each exam room. "So it's also used as a patient engagement tool," Wilson-Jones says. "They don't have to log in. They don't have to look the patient up. RheumShare shows pain trends on each RA patient's various points of interest.

"The physicians designed the screen, so it's what they wanted to see and how they wanted to interact with it," Wilson-Jones says. "They actually use it in the conversation with the patient."

Another application for managing chronic care management lets Sutter physicians prepare for a chronic case visit or encounter. "When preparing for these complex chronic cases, it takes them a lot of time to go through Epic and hunt and peck to find all the data," Wilson-Jones says. She referred me to a recent data visualization, "A Day in the Life of Dr. Jones," shown at HIMSS, which describes how during a 16-hour period, with 24 visits, a physician had to make 2,541 clicks in the EHR.

The Sutter chronic care management app, like a number of other EHR overlays I've been learning about lately, greatly reduces this hunt-and-click requirement to conduct the kind of work that physicians have to do every day. At Sutter, it's already moved beyond the pilot stage and is in use with more than 500 physicians.

Such apps also are increasing patient engagement, because physicians are increasingly sharing these screens with patients during encounters. It turns out that dashboards aren't just for staff anymore.

Sutter RD&D also measures what portions of all these apps its clinicians are actually using, and for how long. "Through clickstream analysis, we can find out what in the application is of value, and what's not," Kristen-Jones says.

Measure what you do. Celebrate what's working. Change what doesn't work. Make busy professionals more productive. Technology has no higher calling in healthcare.