OK, so information is power. But does information alone have the power to transform healthcare? To help people make healthy lifestyle choices and get patients fully engaged in their care? Can healthcare information technology transform healthcare -- as so many say we must -- from a system that treats disease to one that prevents it?
There are plenty of folks who are trying to use data and technology to do just that--from physicians to the government to patients-turned-advocates. Many of their ideas to use healthcare data to empower patients were on display at last week's Health 2.0 conference in San Francisco. They ranged from hot apps to cool gadgets to interactive websites as adorable and non-threatening as a game of Farmville or Angry Birds.
I admit that I was fascinated by all of the wares on display. But my inner skeptic wants to know: Where are the technologies, tools, and solutions that will engage patients who just don't care about their health that much in the first place? Or those who don't have the time, resources, or energy to take on the task of getting and staying healthy?
Getting healthcare data and information into the hands of engaged patients is a lot less of a challenge than reaching those who are not.
Developers are banking on techniques like "gamification" (a horrible word to describe health-related web sites that have game-like interfaces and qualities) as a way to get folks to learn about their health and use their healthcare data to improve it.
Then there's the Facebook effect: Many online platforms are mimicking the social media platform -- and some have functions that allow users to post their health stats directly to Facebook for friends and family to "like."
But if being an engaged patient were as easy and as fun as playing Farmville or Angry Birds, America would be the healthiest population in the world.
As one of the folks I was sitting next to at a session said, after seeing a demo of one of these game-like sites: "That's great. But does it work?"
I'm a healthcare technology reporter. And I was covering a healthcare technology conference. So of course many of the solutions were high-tech: slick, expensive, complicated, or some combination of the three. And they're great for those patients who really do hunger for more data about their health and have the time, energy, and desire to use it.
Someone who worked for months to lose 60 pounds or who has been smoke-free for six months will be tickled to brag about it on Facebook. Exercise freaks will be stoked to have an app that charts and graphs his or her heart rate and ratio of fat to muscle mass.
The family that eats fast food four nights a week, the couch potato who only moves to shake the last of the chips out of the bottom of the bag, or the mother of two with a full-time job who wants to lose weight but cannot find a spare minute in her day, let alone an hour to go to the gym? Not so much.
To be clear, I'm not dismissing any of the innovative ideas presented at the conference. We are making great strides toward getting data into the hands of those patients who want it and know what to do with it.
And for those who are not quite there yet but want to be, the government is taking action to educate patients about health information and the technologies they can use to access and interpret it. High-tech body sensors that track blood pressure, heart rate, steps, and more will appeal to the large and growing population of gadget geeks.
But there's still a crying need for easy-to-use (dare I say low-tech?) solutions to the problem of public health (or lack thereof). I'm talking about solutions that require as little effort on the part of the non-engaged patient as possible.
There were a few disarmingly simple ideas that stood out for me, including one from the Society for Participatory Medicine that uses data in a way that has the potential to reach lots of people in a way that can be easily understand.
The organization is aiming to certify 10,000 physicians as being adept at partnering with their patients to improve health. Much like those "People love us on Yelp" stickers you see in restaurant windows, the group's seal of approval would identify physicians who meet the organization's standards for participatory medicine: Providing patients with their own personal health data, getting input from patient advisors to guide their practices, and providing other medical resources to patients.
Healthcare data needs to be widely accessible and easy to understand. Once we've accomplished that, let the Angry Birds games commence.
You think eHealth is all about the apps and software? While it is true that the vast majority of eHealth tools featured at the Health 2.0 conference in San Francisco exist only online or in smartphones and devices, there were several devices folks can actually touch at the show.
Although most of the devices are aimed at consumer end-users, there are benefits to healthcare organizations. For example, devices that allow patients to share their data can help docs track patients after discharge, allowing them to intervene if a patient shows signs deterioration--possibly heading off a visit to the ER or a readmission.
Rehabilitate in a box
Vlad Shlosberg, Roderick Escobar and Sheetal Shah won the conference's code-a-thon contest with a device they call simply "The Box." A Microsoft Kinect gaming system, equipped with motion-sensor technology, tracks patients recovering from cardiac events as they perform rehabilitation exercises.
Doctors can check in on results through a tablet application that records the information and a video conferencing tool lets doctors and patients conduct remote visits. The portable device is encased in a hard-shell pelican case--a healthcare organization could rent or lend it to a patient until rehab is complete.
The box is also budget-friendly. Over the two-day code-a-thon, team members, all employees of tech firm Avanade, dashed through the city to buy about $470 worth of parts and supplies, passing through the notoriously free-spirited Folsum Street Fair on the way.
The price point impressed the judges.
The team used inexpensive and commercially available materials to do something that would have cost $5,000 to deliver two or three years ago, code-a-thon judge Jan Gurley, MD, a San Francisco public health physician and administrator, told Health 2.0 News. "The notion that you could put together a box whose ultimate cost was under $500 and could do all the things that it’s advertising it can do means that you could have a huge splash and that commercialization might actually work." she said.
Wear your heart on your wrist (or your arm)
Basis Science launched a heart and health monitor wrist strap that was voted an audience favorite.
The $199 tracker has multiple sensors, including an optical blood flow sensor that measures heart rate and a 3D accelerometer that records movement, including while the wearer is asleep. It also tracks body heat levels to measure calorie burn rate and sweat levels to track the intensity of a workout from warm-up to recovery, according to the maker, which is based in Vancouver but has an office in San Francisco.
Connect the device to the computer and a Web-based dashboard show the stats in graphic format and makes personalized wellness recommendations. Users can share their stats on social network sites and share results with their doctors.
Another health tracker device featured at the show: an armband that automatically captures more than 5,000 data points per minute on sweat, body temperature, heat flux, motion and steps, and sleep activity. The BodyMedia Fit Core armband includes an optional display device that can be worn as a wristband or clipped on clothing and provides updates throughout the day.
An online component has a food journal and analyzes the raw data on calories, sleep and patterns, and offers personalized recommendations. There's a mobile phone app, too.
Wear your heart on your ear
A personal hart rate monitor, which also made its debut at the show, is touted as a stress-management tool. Using a small ear clip, the monitor tracks an individual’s heart rate variability and provides feedback via its mobile and web applications on how to reduce variability through slow breathing exercise. MyCalmBeat was created by Brain Resource, Ltd.
Track your health on the cuff
A blood pressure cuff that connects to an iPhone, iPad, or iPod Touch and allows users to measure systolic and diastolic pressures as well as their heart rate. Results are displayed in real time and stored so users can track their progress over time. The Withings device also allows users to send results to their physician via email.
Weigh in on smartscales
Another Withings device, a Wi-Fi smartscale tracks weight, fat mass, muscle mass, and BMI. Users can track results over time for multiple users online or with an Android device, iPhone, or iPad. Users can send results to their care team, as well.
There's been lots of talk about meaningful use of health information technology in the past year and a half, but one user is often left out of the conversation: the patient.
If discussions at the Health 2.0 conference in San Francisco this week turns out to be more than just talk, that's about to change.
In two separate sessions, officials from the Office of the National Coordinator for Health IT conceded they have not paid enough attention to patients in developing HIT policies and programs. "We come to this community with humility," said Farzad Mostashari, MD, ONC's national coordinator for health information technology. "This is not something that I personally have been at the forefront of fighting for. But I really do believe we're on the right track, here."
That need to better incorporate patients and consumers comes not from within ONC, said Lygeia Ricciardi, ONC's senior advisor for consumer eHealth, a job that was created less than a year ago. Rather, it comes from paying attention to the types of folks who are creating eHealth technologies designed to engage patients in their care.
"Technology is changing every aspect of our lives," she said, "And that's beginning to come to healthcare."
Ricciardi outlined some of ONC's consumer-focused goals, which include:
Giving consumers access to their own electronic health data. They've had the right to access their own data for a long time, Ricciardi said, but it's been "pretty darn hard."
Making patient data more actionable so that patients know what to do with it once they access it. Again, tools unveiled at the conference will help achieve that goal, she said.
Shifting and changing attitudes about ownership of health data. Physicians and providers have not always been willing to share data with each other, let alone with patients. That's changing, she said.
One town hall audience member asked how the agency intends to reach those goals. Specifically, how can ONC and the industry in general convince consumers that it is OK to walk into their doctor's office and ask for their health data and how can providers ensure that patients get those records and get them consistently?
Mostashari said the agency can't do it alone.
"We don't own consumer eHealth in any way, shape, or form," he said. "We are at best enablers and sometimes conveners. But we recognize that the real strength of this movement comes from out there, from all of you."
For example, he said, nurses are willing and uniquely able to advocate for patients and help them in getting access to their healthcare data. That's the kind of partnership that will drive the movement, he said. Caregivers and family members can also play a role, he said.
ONC is also promoting its new website, healthit.gov, which has information about health IT for consumers and healthcare professionals as well as its new Consumer Health IT Pledge initiative.
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. ONC representatives also touted the Blue Button Initiative, a platform that makes it easier for patients to download their medical records.
Patient engagement is a core piece of meaningful use of electronic health records, Mostashari said. Meaningful use requirements sets the groundwork for "massive liberation of patient data" for patients, providers, developers, and innovators to help patients take better care of themselves, engage more in their care, share information, and help coordinate their care.
"All too often it is the patient who is not just the courier of their records, but the one in the best position to coordinate their care."
The conference concluded on a patient-centric note, with a "Patients 2.0" panel discussion. Several patients and patient advocates had a chance to ask direct questions—created during a patient crowdsourcing exercise—of Mostashari and Ricciardi.
Mary Cain, a healthcare technology consultant and one of the patient representatives on the panel, noted that the government has spent $20 billion getting electronic health records into the hands of providers. Where, she asked, is the $20 billion for patients to access and interpret their health data?
Mostashari again pointed to conference attendees. "There's a lot of folks I met today who are creating applications and services and new innovative services for keeping people healthy," he said. "The single most exciting thing I've seen today is you all voting with your feet and your wallets and your investor's wallets that there's going to be a market for keeping people healthy."
Creating popular applications and marketing them direct to consumers is relatively easy. Creating healthcare apps and marketing them directly to patients with specific conditions or health concerns poses a few more challenges.
But there's nothing easy about developing technology products for healthcare organizations—in fact, there's a whole long list of barriers standing in the way of innovation.
Some of the country's most innovative healthcare organizations—including nine that are part of the Office of the National Coordinator for Health IT's Beacon Community Program—networked and shared ideas in San Francisco on Sunday with startups and entrepreneurs who are trying to develop the software, platforms, devices, and other products that will help solve challenges from getting patients more engaged in their healthcare to improving clinical quality.
The Sunday event, a kickoff to the fifth annual Health 2.0 conference, included sessions on patient engagement, connected doctors, legal issues, and more. New this year was an "Innovation Exchange," a half-day meeting between nine Beacon communities and a room full of developers held in collaboration with the ONC's Beacon Community Program.
The Beacon Communities at the event represent a significant opportunity for developers: They have an average of about $15 million each in total ONC funding over three years. And while most projects are already underway, some Beacons are considering additional consumer eHealth technology, conference organizers noted.
One major theme that emerged throughout the day and across all sessions is that when it comes to healthcare innovation, the healthcare industry itself is one of the biggest barriers to success. The following are just a few:
Costs: Healthcare organizations are concerned with costs in two ways. First, they're focused on finding ways to reduce costs. Second, they're not willing to invest in solutions that will do that. Developers at the show expressed frustration that the onus is on them to create solutions, but healthcare organizations aren't always willing to share the risk and invest the time necessary to create useful products.
Standards: From the providers' perspective, healthcare technology products can't just be fun to play with—they must meet specific criteria. They must address a clinical need, reduce costs, be easy for patients and for clinicians to use, and they must be easy to integrate into the complex and ever-changing workflow and organizational operations. That's a tall order for many developers. Those who don't pay attention to their customers' needs won't succeed.
Evidence: Doctors, in particular, want hard evidence that a new tool will save time and money and improve clinical quality. The healthcare industry is used to an adoption model that begins and ends with research. Developers are clearly struggling to meet that high evidence-based bar.
Laws and regulations: No surprise here that healthcare is a highly-regulated industry—but developers who are new to the healthcare realm often don't understand the extent to which this is true. Let's face it, people who work in healthcare sometimes don't understand HIPAA. And the FDA's promise to step up regulation of healthcare apps is also daunting to developers—and their investors.
Pace: The tech world is used to moving quickly, getting new ideas to market and into consumers' hands (or iPhones) before they're outdated. And as we all know, healthcare is not a nimble industry. Both providers and developers at the conference say the industry must figure out some way to meet in the middle.
Too many choices: There are barriers to even the simplest Health 2.0 products. Conduct a search in the Apple store for "health" or "healthcare" and you'll get an overwhelming number of results. And many of them have few or no reviews. Healthcare apps aren't Farmville—docs don't want to make blind choices on apps that might not be useful.
The folks attending Health 2.0 are fervent in their belief that innovation in healthcare will come from outside of the industry. In fact, there's an argument to be made that innovation must come from outside of the healthcare industry—that fresh eyes and new ideas are the only way to affect change and that the healthcare industry, for the most part, isn't capable of doing it on its own.
Those outsiders are courting healthcare. The question is whether or not they'll ever get past the first date.
The e-health market is bloated with simple tools for patients—online weight trackers and apps that offer exercise and diet tips, for example. And there's no dearth of physician tools that aid decision support, diagnosis, or provide access to medical references.
So where are the opportunities in e-health—those markets that aren't already flooded with products and crowded competitors? Some clear answers to that question are emerging at the fifth annual Health 2.0 conference in San Francisco this week.
Review and certification
One opportunity has arisen precisely because there are so many similar eHealth tools from which to choose. The industry needs reliable, reputable sources in the public and private sectors to vet them or even professional associations that could certify them, Marco Smit, president of Health 2.0 Advisors said during a small-group discussion on Health 2.0 white spaces.
Browse the medical category in Apple's App Store and you'll quickly see why there's a need — there are a lot of applications listed, but many are unrated or have only a few contradictory reviews. You could scroll and click all day and still not have a good idea of whether or not an app is worthwhile.
"Curated content" could include peer and expert reviews of apps, for example, and clinical studies as to the efficacy of e-health tools.
Quantified cost cutting
With the healthcare industry's focus on cost-cutting, tools that help providers and hospitals reduce readmissions or improve workflow and efficiency, for example, are in high demand. In fact, cost-cutting tools are the biggest opportunity in eHealth right now, said Mark Smith, MD, president and CEO of the California Health Care Foundation at the conference's opening keynote address. It might sound obvious—after all, no one develops a product designed to raise costs or waste money, he said.
But developers don't always quantify their cost-cutting claims and they don't always do a good job making sure the entity that's investing in the technology is the beneficiary of the savings, he said.
Patient-centered products
Another clear message from speakers and attendees is that eHealth tools must be designed with patients in mind. And that goes for tools designed for physicians, as well.
Enoch Choi, MD a physician who practices at the Palo Alto Medical Foundation wants technology to get out of his way. He wants tools that help him connect and communicate and build relationships with his patients—not ones that give the impression he's hiding behind a mobile device or computer screen, he said in a "Doctor's 2.0" panel discussion.
Too often a technology—even those that improve clinical quality—add so much to the physician's workflow that it hampers the physician-patient relationship, said Lyle Berkowitz, MD, director of the Szollosi Healthcare Innovation Program, who also spoke on the panel.
Better use of data
Developers are looking for ways to use the vast and growing store of data in all kinds of tools for payers, providers, clinicians, and patients. For example, physician rating sites could go beyond written patient reviews and incorporate multiple data sources, such as quality and competency measures, to create a rigorous 360 degree physician review.
Personalization
Another area where data creates opportunity is in the field of online patient communities. The 1.0 version allowed patients to interact with each other, blog about their experiences, and perhaps access to some content. The 2.0 version uses the patient's own healthcare data to create a rich, customized experience.
Ease of use
In order for any new product to succeed it must be easy for the end user. Healthcare is "so damn inconvenient" Smith said. To succeed, new products must make healthcare easier for patients to navigate the system.
That goes for clinical tools as well.
New products have to be revolutionary for docs to adopt, Choi said. "It has to fit into the workflow seamlessly and really help us connect with our patients and be useful."
One of the goals of the Health 2.0 organization is to connect healthcare organizations and health tech start-up companies in part through two contracts with the Office of the National Coordinator for Health IT under the Investing in Innovation program, including one that funds a developer challenge.
More than 100 companies are demonstrating new products at the Health 2.0 conference.
As part of a large-scale government and industry effort get patients more engaged in their care and to ensure they have better access to their own health data, the government wants to allow labs to release test results directly to patients.
The proposed rule, sponsored 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.
Patient advocates praise the idea, while some physicians oppose it.
Empowered patients
"What we're hoping this regulation will help achieve is for the healthcare system to become more responsive to patients in general, but at the same time give patients direct access to their information when they want it, Alice Leiter, director of health IT policy at the National Partnership for Women & Families, said in an interview.
"This direct access should strengthen the partnership between patients and clinicians, rather than leaving patients in the dark with respect to their own health information."
The move "empowers patients to become true partners in their healthcare decisions, promotes the transparency our system needs, and ultimately helps us use our healthcare dollars more wisely," Christine Bechtel, vice president of the non-profit women and families partnership and a member of the federal Health IT Policy Committee said in a statement.
At least one national lab, Quest Diagnositcs, is also in favor of the rule.
"Patient engagement in healthcare decision making is vital to promoting better health outcomes and reduced costs in our healthcare system," Surya N. Mohapatra, Quest's chairman and chief executive officer said in a statement. "HHS's proposed rule will help to empower patients to understand their health condition and discuss their healthcare options more constructively with their physicians."
Cost considerations
But it's not as simple as it sounds, Bernard Emkes, MD, medical director managed care services at St Vincent Health in Indianapolis, said in an interview. For starters, there's the question of whether labs have the right technology to meet the demand and what the rule would cost labs and, by extension, consumers.
"The lab has pretty good structures in place to get a lab results to my office. But they don't have anything in place to get a lab result to an individual patient's home phone number," Emkes said. "There's going to be a huge infrastructure cost for having the lab provide that directly to patients."
Leiter contends that the move would save money by reducing duplicate tests after results go missing and by improving quality of care.
"Any time we can empower patients with information and get them more active and involved in their care, the resulting stronger partnership between patients and their care team will in the end reduce costs. Patients who are engaged and getting the care they need and want means better management of healthcare and healthcare service and more effective and efficient patient care," she said.
Interpreting results
Another obvious issue with direct-to-patient lab results: Most test result reports are not designed for the layperson.
"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," Emkes said. "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.'"
Bechtel and Leiter both agree that patients need help interpreting and understanding lab results. In fact, Leiter said, the rule would support that goal, allowing 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."
Further, she added, the rule doesn't force patients to get their lab results directly—it just gives them the option to do so.
"The idea that people won't give patients information about themselves that's legally theirs because they think patients won't understand it is no reason to oppose this rule," she said. "We don't disagree that accompanying context, explanation, and education is preferable, but we also do not believe in the idea that patients fundamentally are not equipped to decide whether and when they want to go back to their doctor with questions. This is about allowing those who want to get informed to get informed, and then decide how to use the information they receive like they would any other information in daily life."
Communication
Missing, delayed, or incorrect test results are often blamed on a variety of factors: the number of different testing locations, the large number and variety of tests, and inconsistent reporting processes.
"This is primarily a workflow issue," Leiter said. "Especially in primary care settings, where doctors and their staff are incredibly busy, are managing multiple patients, and are often struggling to coordinate multiple dimensions of an individual's care, it can be difficult to be as responsive as patients want or need … Sometimes it just takes too long to wait for the mail or a call from your doctor or for the lab to deliver the results to the doctor—who then needs to interpret them and then have a staff member call the patient. It's not hard to see how things can fall through the cracks with that many steps."
Although Emkes says it is a doctor's duty to get test results to patients in a timely manner—when he was practicing he would call patients with results each night—he agrees that the process of communicating lab results is complex.
Doctors get results from a variety of sources—multiple labs and different hospitals and health systems, Emkes said. "And they're all in a different format and they're all in a different layout. It's really hard for me to pick up the abnormalities … because every one of those is formatted differently."
Technology
One solution to these problems can be found in health information exchanges, Emkes said.
Physicians who are members of the Indiana Health Information Exchange, for example, can choose how they want their lab results formatted and packaged, he said, making it easier to read, interpret, and deliver the findings to patients in a timely manner.
"I think we absolutely positively have to move toward more electronic connectivity," Emkes said.
But even the efficacy of health information technology is up for debate.
Not all patients whose doctors use electronic health record systems or patient portals have online access, Leiter said. "Patient portals are certainly a great way to deliver lab results and we hope we see more widespread use of them. But right now all patients deserve the ability to see their information in a timely manner."
The way Americans pay for healthcare services is changing—and as a result healthcare providers will be forced to take on new or expanded roles as benefits educators and administrators, financial counselors, creditors, and collectors.
HealthLeaders recently convened a panel of experts in Boston to discuss how healthcare organizations can adapt to the new landscape. We talked about a range of topics—from patient financing to outsourcing collections to honoring your mission and protecting your brand while you mind your bottom line.
Insurance models are becoming more and more complex—high deductible plans, co-pays, co-insurance, and different tiers of coverage can confound patients. So who will be responsible for education? And how can technology help?
"It's challenging from a patient education perspective: telling patients why they owe more money than in the past, interpreting new rules, helping patients into the right programs, and helping them understand those programs," said Thomas Yoesle, chief operating officer patient financial services at Orlando Health.
"Technology can play a huge role in helping consumers understand their plans, their benefits, and the amount they must pay out of pocket," added Deborah Lelinski, Director Product Management at Ontario Systems, which sponsored the roundtable event. "Right now, it's very difficult to realistically predict the cost of service when the complexity leads us to answer with 'It depends.' "
Meanwhile, online education has its benefits, but face-to-face interactions might be important as well, Yoesle said. "As much as I want to push this education and information to the Web, I think we'll start hosting workshops and using kiosks to answer questions about benefits and plans and then push those FAQs to the Web."
Richard O'Donnell, vice president of payer strategies and contracting at Trinity Health also noted that insurance exchanges could take on the role of interpreting benefit design.
Even so, said Timothy Reiner, vice president of revenue management at Adventist Health System, "we're still going to have to engage the patient in different ways once those exchanges become more prevalent in the various states in 2014. It may be online portals or other strategies. There is a lot we don't know, but clearly one of the tenets of meaningful use is to engage the patient more online in their care—including their financial responsibility."
2. Estimating payments
When you walk out of a dentist's office, the person at the front desk has a pretty good idea what you'll owe—and it's rare a patient walks out the door without paying at least part of it.
So why not in hospitals and physician's offices?
"Estimating benefits is something that we've struggled with from the Stone Age," Reiner said. "As a provider, you've got to decide whether to invest in additional technology beyond just pushing a button and sending a transaction to the payer or screen scraping [capturing computer screenshots and putting them into a database]. We should be so much better than this."
"We need what I would call real-time patient liability estimators—complete interconnectedness between health plans and the clearinghouses and the providers," O'Donnell said. "Patients should be able to log onto a portal to determine their unmet liability, he said, even if that means adding disclaimers that it might not be 100% up-to-date." It's so much better than having someone asking 20 questions to identify your possible out-of-pocket liability that may still be inaccurate."
3. Securing payments
At a hotel, your bill is computed before you check out—usually they've slipped it under your door in the night. And there's no walking out the door without settling up. So how can technology help hospitals catch up to dentists and hoteliers?
"As we move toward more EMRs, documentation will drive the charges," Reiner said. "If you're documenting a level 3 evaluation and management visit, you know that by the time the patient is ready to walk out the door. That claim could be adjudicated, as with the pharmacy model, and you would know your co-pay is $35. There's no reason that episodic physician visits can't be done like that.
Inpatients are a little different, but the only reason that it can't be done is because the payers don't offer it and there's not a singular work flow for it."
But what about the risk that physicians will miss a charge if they don't properly document the visit?
Reiner says he's willing to take it. "If we made a charge capture error, we'll take our lumps. It would be better to miss a charge but get the payment at time of service."
Technology is everywhere in the surgical suite—from the smallest medical gadget to the largest, most expensive piece of imaging equipment or robotic system, to the electronic medical record system that ties it all together.
The latest HealthLeaders Media Breakthroughs Report on high-performing surgical programs centers on four organizations that share how they used technology to create more efficient, quality-driven, patient centered, and successful surgical programs.
1. Don't buy what you don't need
There was a time not so long ago when surgeons heard about a medical device, decided they wanted the shiny new toy, put in an order, and gleefully await for their shipment to arrive. "There were no questions asked, there was no discussion done, and it led to the proliferation of a lot of technology that was quite useless," Michael L. Marin, MD, chair of surgery at The Mount Sinai Medical Center in New York City, says in the multimedia report.
Those days, he says, are over.
"The paradigm has shifted. Certainly it has at Mount Sinai, where we have a much more financially responsible approach to the use of technology."
Before a new technology or device is adopted at the organization, a committee conducts a cost-benefit analysis of the device's value to the patient to determine its potential economic impact on the hospital, Marin says. "We now walk into the use of new technology with much greater knowledge and more careful forethought than we ever have in surgery in modern times."
2. Don't pave the cow path
Hospitals spend millions of dollars on new programs, platforms, and tools "with the expectation that the transformative power of technology will also transform surgical services into a high-performance, high-tech/high-touch driver of future profitability and quality rankings," says Lawrence Hanrahan, MD, a principal at PwC Health Industries Advisory.
"It's possible, but not guaranteed," he adds.
In order to get true performance you must also address fundamental people and process issues—workflow, roles, and responsibilities.
"The introduction of new technology in the surgical services area may result in 'paving the cow path.' It may look like a new road, one that is greatly improved and can handle far greater volumes of traffic at higher speeds, but it is still utilizing the same operational process or work flow," he says. "At the same time, your competition is utilizing the 'new superhighway,' which has bypassed your old way of doing things operationally.
Organizations must anticipate and manage the change and its impact.
3. Put your technologies in the right place
A multi-purpose outpatient center has the power to improve operational efficiency—allowing services to share large and expensive technologies, for example. One such center allowed The Methodist Hospital in Houston, TX, to share the MRI suite with 10 centers that use the same technology, says Roberta Schwartz, senior vice president of operations.
"What we did with the building is try—to the best of our ability—to co-locate services that made sense," she says. "For services such as cancer that have all-encompassing services, we gave them a home. This is the first building where they've really had a comprehensive home for all cancer services, and that was inclusive of their location for tumor boards, their physician clinics, their infusion space. Cancer isn't located on six floors; they've got a floor in the building. Could we have built a stand-alone cancer center? Sure. But we could co-locate that with all of the imaging services that they needed."
Similarly, Bassett Healthcare in Cooperstown, NY, was aiming for safety and consistency when it consolidated surgical services. "There is a cost for quality—the cost of a piece of equipment. Do you replicate it five times or do you ask patients to travel some distance?" says Lorraina Smith-Zuba, RN, Bassett's director of perioperative services.
St. Francis Hospital in Roslyn, NY has a new building with 17 operating rooms and is opening six new ORs, one of which is a hybrid cardiac endovascular suite that enables imaging and surgery in one sterile environment.
The hybrid ORs will help with a national percutaneous valve implants trial it's conducting. "We're currently using our cath labs, but the cardiac hybrid is the ideal location. Just the technology alone, the robotic nature of the c-arm, and being able to convert in seconds from an imaging facility to an operating facility is going to make work a more pleasurable experience," says Newell Robinson, MD, chair of cardiothoracic and vascular surgery.
The theme common to all three tips—and at all four organizations in the report—is careful planning.
Bob Nimon, managing director at Genesis Planning, a healthcare technology consultancy, and manager of medical technology planning at The Methodist Hospital, says technology can account for as much as a quarter of the building costs, but given construction lag times and other strategic decisions, that cost may be difficult to pin down. At the time the center was being conceptualized in 2005, the health system could not say exactly what surgical and other outpatient services would be in the building, Nimon says.
"In order to accommodate not knowing what physicians or services were going to be using these ORs, and not having an exact handle on what procedures were going to be done in the future, we came up with a layout of the ORs in terms of the utility booms, lights, integration, and all of the different elements that could accommodate multiple surgical interventions on a multidisciplinary basis," Nimon says. "We worked with the hospital, architects, and engineers to make sure that these adaptations were planned and that the staff understood what we were doing so they could get best utilization out of these spaces later on."
Hospitals must consider the impact of new technologies on clinical and nonclinical workflow and operations, Hanrahan says.
"It is less about the specific surgical instrumentation or clinical technologies or the electronic medical record, but more about the necessary training of current staff and change implications, even in terms of shaping the new job description and rethinking the type of person that you want to hire going forward. So we tend to be more focused on ensuring that the appropriate change management program is put in place across all the stakeholders and how you're going to communicate to all of them of the new requirements and expectations. Executing that change management over the specific time frame to help achieve those safety objectives and efficiency objectives—that sounds great theoretically, but there are always some additional pieces that need to be put in place beyond the specific piece of technology.
You can read more about how these organizations are improving their surgical programs in our most recent HealthLeaders Media Breakthroughs Report, The High-Performing Surgical Program.
A proposed rule drafted by three federal agencies would allow patients to receive their test results directly from labs—with no doctor playing middleman.
The Centers for Medicare & Medicaid Service, the Department of Health and Human Services' Office for Civil Rights, and the Centers for Disease Control and Prevention, would amend the Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations and HIPAA privacy regulations and is part of a larger effort to strengthen patients' rights to access their own medical records.
"Patients have a right to access and use their health information," Farzad Mostashari, MD, the national coordinator for health information technology, said at Monday's first-ever HHS Consumer Health IT Summit. "And we are here today to make it easy for them to exercise that right."
Under the proposed rule, labs would be authorized to release results to patients or their designated representatives upon request after authenticating that the results belong to the patient.
"When it comes to healthcare, information is power. When patients have their lab results, they are more likely to ask the right questions, make better decisions, and receive better care," HHS Secretary Kathleen Sebelius said at the summit. "In the past you often had to wait days or weeks to get the results from your doctor… Under this rule you'll be able to get your results directly and act quickly if there is a cause for concern."
CLIA covers all phases of laboratory testing, including the reporting of test results. Under the current regulations, CLIA limits a laboratory's disclosure of test results to three categories of individuals: the "authorized person," the person responsible for using the test results in the treatment context, and, in the case of reference laboratories, the referring lab.
An "authorized person" is defined as the individual authorized under state law to order and/or receive test results. In states that do not provide for an individual's access to his or her results patients have no option but to receive their results through the provider who ordered them.
"We believe that the advent of certain health reform concepts (for example, individualized medicine and an individual's active involvement in his or her own health care) would be best served by revisiting the CLIA limitations on the disclosure of laboratory test results," the proposed rule states.
The proposal notes that some stakeholders—including providers, labs, health exchange organizations, and others—contend that the current rules impose barriers to the exchange of health information, impede individuals' access to their health records, and prevent patients from taking a more active role in their personal health care decisions.
There were two other announcements at the HIT summit:
Secretary Sebelius announced the appointment of Leon Rodriguez as the Director of the Office for Civil Rights. He will be charged with ensuring consumers' health information is kept private and secure.
"Consumers need to know that private and secure access to their health information is a given," OCR Director Rodriguez said in a statement. "The privacy and security of health data will be a top priority for OCR during my tenure."
Sebelius also unveiled a voluntary Personal Health Record (PHR) Model Privacy Notice—touted as an easy-to-read, standardized template that will allow consumers to compare and choose PHR products based on privacy and security policies and data practices. The new template is similar to the Nutrition Facts Labels, Sebelius said, in that it presents complex information in a simple way to improve transparency and consumer understanding about data practices.
Mostashari said the label was created with input from consumers, and added that the FTC has agreed to enforce its use for entities under its jurisdiction. A handful of vendors and providers who offer PHRs have already pledged to post the noticed on their websites.
outcome measures such as blood sugar, blood pressure, and cholesterol control,
patient-driven issues such as obesity and smoking
Nearly 51% of patients in EHR practices received care that met all four quality standards, compared to just 7% of patients at paper-based practices. Nearly 44% of patients in EHR practices met at least four of five outcome standards, compared to about 16% of patients at paper-based practices.
The study is among the first to put hard numbers on the benefits of electronic health records. But as the study's lead author, Randall Cebul, MD, said in an interview this week, "51% is 49% short of ideal."
So what are the next steps? And how can health information technology get us there?
The problem of patient compliance and engagement
One finding of the research was that the benefit of electronic records was greater for care standards than it was for outcomes. And care standards that are largely patient-controlled—such as smoking and obesity—have been particularly troublesome.
"I guess it takes a village to attack all of the more behavioral-related and adherence-related issues that are most relevant to patients when they're living outside of the doctor's office, which is virtually 100% of the time," said Cebul, who is the director of Better Health Greater Cleveland, a nonprofit healthcare alliance focused on improving the health of chronic disease patients in Northeast Ohio.
Personal health records can help, he said.
"The personalized health records in big electronic medical record systems … enable patients to see their results, to see what is needed in terms of either health maintenance or monitoring of a particular condition, to communicate with their provider when in their home," Cebul said. Giving patients access to the ways in which doctors are thinking about their care and the results of their care will help engage them.
"When we prescribe medicines, we expect or hope that the patient will fill the prescription. In the new world of e-prescribing, there will be mechanisms by which we will be able to determine adherence to medications," Cebul said. "That will help us to recognize reasons for less-than-optimal control of chronic conditions and help engage the patient a little bit more effectively."
Strengthen connections of all kinds
Diabetes patients, in particular, need a lot of services that aren't always provided by their primary caregiver. It's easy to lose track of those visits with paper health records. In fact, it's difficult to track them even with electronic records, since those specialists don't often have EHRs of their own and, when they do, those EHRs are not always connected to the primary care provider.
"The connection between primary care and especially ophthalmology is not as tight as it could be. Most of the practices that we report on do not have ophthalmologists on site. That ends up being a structural barrier to doing better," Cebul said.
"We need to make certain that our ophthalmologist colleagues have electronic health records [and then link] those electronic health records to the practices. The fact that somebody out five miles or even a mile from you where you're practicing has electronic health records is very nice, but if they're not connected then that information is siloed."
If a doc doesn't know a patient has received an eye exam or a foot exam and doesn't document it in the record, he or she can't assume that it's been done, Cebul said. And you don't get credit for improving quality if it's not documented.
Share best practices as well as data
Under National Institutes for Health guidelines, anyone at risk for diabetes should get the pneumococcal polysaccharide vaccine. The MetroHealth System in Cleveland has adopted the standard but was having limited success meeting it, says David Kaelber, MD, MetroHealth's chief medical informatics officer. The organization, which is part of the Greater Health collaborative, got a bump in vaccine rates after it added EMR alerts for docs. The numbers jumped again with some physician education, but MetroHealth still wasn't meeting its goal of compliance in the 90th percentile.
In the end, taking doctors out of the picture was the change that made the difference. Making the vaccine part of the standard orders and empowering nurses to deliver them without asking for a doc's permission pushed MetroHealth’s compliance levels into mid- to high-90s.
Sharing such findings among collaborative members has changed and improved the way individual physicians practice, Kaelber said. Sharing data is important, too.
"Just by reporting quality in a standardized way across many providers and institutions, we are literally a catalyst for improving that quality," he says.
Technology alone isn’t a magic pill for healthcare, clearly. But technology tied to quality standards can help medical professionals and patients alike track care, remain accountable for improvements, and meet society’s goals.