Research proves it: Patients and caregivers alike "universally hate" CDs as a method of transferring image files. That's according to Jeffrey Carr, MD, part of a research team at Wake Forest University in Winston-Salem, NC, that's investigating alternative image-sharing technologies.
To be fair, those are just initial survey results, Carr says. But it sure makes sense.
Usually patients themselves have to schlep CDs from one provider to another—often carrying them to their primary care provider after a trip to the ED. And when the discs arrive, there's no guarantee the receiving organization will be able to open or read them.
For their part, staffers and clinicians waste a lot of time struggling to open and read CD images from incompatible systems. One orthopedic surgeon told the researchers it takes 20 to 30 minutes to load outside CDs into his system. That adds up to a lot of wasted time.
And when clinicians don't have reliable access to patients' images, they may have to repeat tests, delaying diagnosis, adding to the cost of care, and causing unnecessary radiation exposure for patients.
Backed by millions in federal grant money, Wake Forest, the Radiological Society of North America, and other groups are investigating alternatives to low-tech image-sharing tools that are fast, easy, reliable and interoperable—the missing link, if you will, in so many healthcare IT solutions.
The RSNA project relies on Internet-based personal health record accounts from commercial providers to give patients access to their imaging data. Wake Forest uses a token system and walk-up kiosks with card readers at participating organizations—much like the system at an airport check-in kiosk or an ATM.
Both use the same foundation—the Cross-enterprise Document Sharing for Imaging (XDS-I) profile, created by Integrating the Healthcare Enterprise (IHE) International, an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information.
One common theme among projects under development is that they're patient-centered and patient-controlled. The idea is that if patients have more power over who sees their images they'll also be more engaged in their own care and work more collaboratively with their various providers. That, in turn, should improve quality of care.
"Patient involvement will facilitate much easier solutions," says Yaorong Ge, PhD, an assistant professor in the department of biomedical engineering and part of the Wake Forest research team.
Another overarching goal of these programs—and others like them—is to create technologies that are easily accessible and affordable for providers in rural and underserved areas. Wake Forest's Carr says improved efficiencies should help pay for the technology—his team is working to quantify that. Ge adds that the government push to improve broadband coverage combined with intelligent algorithms such as prefetching and streaming, will help speed up image transfer.
Read more about the RSNA and Wake Forest programs in The Trouble with Image Sharing, published in this month's issue of HealthLeaders magazine.
If there's one technology that has the potential to fundamentally change access to healthcare in rural areas, it's surely telehealth. Small and rural hospitals are already taking advantage of the technology for services that are especially well-suited to virtual care, such as dermatology and other consults that benefit from today's high-definition digital cameras and monitors.
Teleradiology's been around in one form or another for a while—it doesn't really matter where images are read, as well as they're read and reported accurately. Telestroke and e-ICUs are also showing up in an increasing number of organizations.
That's backed by the 2011 HealthLeaders Media Industry Survey of technology leaders, which found 46% of respondents already have one or more telemedicine programs in place. Another 41% say they'll have one in place in one to five years.
But there's so much more that the healthcare industry could do—especially with the increase in faster and more reliable networks, wireless devices, high-definition digital images and video, and the ubiquitous mobile device.
This week CMS lowered one of the biggest barriers to telehealth when it implemented a new credentialing and privileging processfor physicians and practitioners who provide telemedicine services.
Under the new rule, hospitals will no longer be required to credential and grant privileges to each physician and practitioner who provides telemedicine services to its patients from a distant hospital or other telemedicine location. Instead, hospitals can rely on the credentialing and privileging decisions of the distant hospital.
And the physician's home hospital—presumably the larger organization, although some small hospitals do lend out their own specialists—will be responsible for the credentialing process.
It makes so much sense it's almost scary.
The problem is that there are still lots of questions about telehealth. If care is delivered across state lines and the states have different regulations, which rules count? Who's responsible for medical errors and who answers to lawsuits? Who keeps the medical record of the visit? Who's responsible for making sure the medical information is secure? Should insurance companies reimburse virtual visits at the same rate as in-person visits? In fact, do they have to reimburse them at all?
There are other folks who are working to come up with answers to these questions. Lawyers, for example, have drafted contracts that deal with malpractice liability. And more payers are recognizing that care delivered with telemedicine technology is likely just as effective as care delivered in person and definitely more cost-effective than allowing a patient to go without care until his or her condition worsens.
Those who see the potential that remote health has to improve access to healthcare—healthcare leaders, clinicians, professional associations, policy-makers, payers, patients—are all working toward answering these questions. You can read about some of those advocates and the work they're doing to advance telehealth in Does E-Health Stand a Remote Chance? the February HealthLeaders magazine cover story.
It took them a while, but the government managed to come up with a simple and elegant answer to the credentialing question. Surely we can do the same for the rest.
You want the leaders at your organization to pay attention to ED throughput and intervene when the wait for a bed gets too long? Put the data on their smartphones. I was in Atlanta recently for a roundtable discussion for our most recent Breakthroughs report, The Coordinated ED. Over the course of the event, it seemed like two of the ED leaders there checked their mobile devices—and the nifty little app that lets them monitor patient population data—at least one million times.
During a phone interview, Leon L. Haley Jr., MD, deputy senior vice president of medical affairs and chief of emergency medicine for Grady Health System pulled out his smartphone and clicked a few keys. "We have two admissions that are waiting for a bed and both of them have a bed," he told me. "They just haven't gone upstairs yet. There are 115 patients in the ED right now that are active, only two of which are admissions."
At Cambridge Health Alliance, which is also featured in the report, leaders have on-site and remote access to ED data via their smart phones, as well. And if the numbers start to stray too high, every administrator gets a page and is expected to pitch in to help solve the problem. They call it "Code Help."
2. Go public
CHA also posts wait times on the organization's web site. The numbers refresh every 10 minutes as the patient population ebbs and flows. Rarely does the posted wait time at the Cambridge location, the busiest of the system's three EDs, break the five-minute mark. Wait times at the other two campuses are routinely just two or three minutes.
That helps community perception of the three EDs which, in turn, builds market share.
3. Send physicians alerts
Cambridge uses an automated program to alert primary care physicians by email and by text whenever one of their patients arrive in the ED. The physicians love the program. Before it was implemented they would often complain that they had no way of knowing their patient had been treated unless he or she was admitted. It's embarrassing, docs said, to have a patient come into the office to talk about an ED visit the doc didn't even know about it.
"It is not unusual for the physician to call and discuss the case," says Assaad Sayah, MD, chief of emergency medicine at CHA. "This is one way we've been able to coordinate care."
4. Aid referrals
More than 60% of CHA's ED patients have a primary care physician but if a patient doesn't have one, an alert system can be used to send a message to the outpatient clinic closest to the patient's home. Then the clinic can follow-up with the patient to help him or her find a primary care physician.
5. Get the picture
Scripps Health is using simulation software to observe and track patients and show their movements through the system visually, identifying bottlenecks, in particular.
"There are certain elements of ED throughput that are very predictable," says Mary Ellen Doyle, RN, vice president of nursing operations at Scripps. "Simulation allows you to do rapid cycle testing, and the cost savings associated with using simulation can be significant."
Read more of the strategies organizations are using to improve their EDs in The Coordinated ED.
"Of course you fell down the stairs and sprained your ankle in Paris," my cousin said to me when I got back from vacation. "It makes for a good story." She knows that I love to tell stories—and experiencing France's healthcare system firsthand certainly makes for a good one.
At the time of my visit to the emergency room at the 987-bed Hôpital Bichat-Claude Bernard, I was slightly too distracted to reflect on how much better my care would be if the doctors could access my electronic medical records. Or print out documents in multiple languages. Or send digital X-rays and a report of the ED visit to my doctor in the U.S.—or at least hand them to me on a CD.
But in retrospect, I'm sure of it.
No one in the emergency room at Hôpital Bichat-Claude Bernard spoke more than broken English, including my doctor. Other than a dismissive wave of his hand, he couldn't communicate the severity of my injury. He wrote a prescription that I couldn't read. I was given no discharge instructions. Just about the only person I understood clearly was the woman who pushed me in a wheelchair to the emergency room exit at the end of my visit and said: "Taxi?"
Most alarming, however, was that the only information collected from me was my name, address, and passport number. The hospital didn't ask for the name of my primary care physician. It didn't ask for my medical history. It didn't ask me if I was taking any medications. It didn't ask me if I have any allergies.
And it certainly never asked for a quick peek at my electronic health records.
I should say that the public health system in France has a good reputation for quality. And they are slowly moving toward adopting PACs. Based on the quick turnaround time I assume the imaging equipment they used was digital (the radiologist didn't know the word "digital," and I didn't know how to describe it in French). But still I had to carry x-rays on film home to my doctor.
As soon as I got home, I went to my doctor's office. Standing at the front desk (telling the story of my adventure, of course) I mentioned that I had received prescriptions for medication but wasn't 100% sure what they were. The nurse practically leapt over the counter to get at the sheet of paper listing the medications I'd received. She spoke enough French to interpret it and asked me the questions that the nurses in France didn't—about allergies, medical conditions that might cause an adverse effect, and the severity of my pain. (Not sufficient, by that time, to warrant the strong painkillers I was taking, she said.)
Perhaps my own story makes me sound like a demanding, spoiled American who expects Cadillac medical care. And maybe I am. But even though I write about healthcare technology for a living, having a personal experience of what healthcare is like without it helped me to better understand its importance.
While interviewing sources for my story on evidence-based medicine for this month's issue of HealthLeaders magazine, one surprising sentiment came up over and over. The healthcare leaders and industry experts I spoke with said some docs don't like decision support technology because they think it makes them look dumb.
When face-to-face with a patient, these sources say, docs don't want to seem reliant on finding the answers on a computer. Is it true?
Well, one study suggests that it is. In the study, researchers read various scenarios to waiting room patients about physicians who used decision support and heeded the recommendation or ignored it in favor of a less aggressive or more aggressive treatment. Participants in the 2008 study, published in the journal, Medical Decision Making, "always deemed the physician who used no decision aid to have the highest diagnostic ability" on a five-point scale, the researchers said.
James Wolf, an associate professor of information systems at Illinois State University's School of Information Technology who studies physician adoption of—and resistance to—technology, saw similar results in his most recent studies. In one, even tech-savvy undergraduate and graduate computer science students preferred physicians who rely on intuition instead of computer aids.
"Patients object when they ask their doctor a question and then she or he immediately types in the question into their laptop and then reads back the answer. It gives patients the feeling that they just paid a $25 copay to have someone Google something for them," Wolf says.
And that perception, in turn, worries doctors. "Physicians are reluctant to adopt computer-based diagnostic decision aids, in part, due to the fear of losing the respect of patients and colleagues," Wolf says.
I'm not buying it.
Think of the alternatives. Physicians who need to double-check information about medication interactions could sneak out of the treatment room to look the information up without the patient knowing—all the while getting further and further behind on appointments. Or they could always just take a stab in the dark.
I could be wrong, but I can't imagine any physician thinks either of those options is a great idea. And I think we should give physicians a little more credit than that.
Still, if there are some docs out there who really are afraid of looking dumb—who are simply incapable of explaining the benefits of decision support to patients and showing them how it can improve the quality of their care—there is hope on the horizon in the form of smarter and smaller devices that will allow access to EMRs embedded with evidence-based best practices.
"Patients won't even be able to tell whether their doctor is using a computer in their diagnostic decision or not," Wolf says. "In that way, it will become more like the auto-pilot used on commercial planes. When we fly, we do not see what is happening in the cockpit, so we don't mind that computers are actually doing most of the flying."
Eventually, clinicians won't have a choice about using evidence-based medicine and decision support in the exam room. Payers, in particular, will demand it.
"It's too late now to say 'if we should have technology.' Evidence-based medicine will not work without technology driving it. It's impossible," says G. Daniel Martich, MD, CMIO at the University of Pittsburgh Medical Center.
"Doctors cannot rely on pulling out the New England Journal of Medicine and reading it and somehow applying that to their patient population. It's not going to work [without full-blown adoption]."
And if some physicians and their egos still can't figure out a way to adapt and adopt? Well, I hope they enjoy their retirement.
The field of telehealth is still emerging, and while there's anecdotal evidence of its benefits to care, there haven't been a lot of long-term studies to quantify it. That hasn't stopped organizations from pursuing the model. In the 2011 HealthLeaders Media Industry Survey of technology leaders, 46% of respondents said they have one or more telemedicine programs in place. Another 41% say they'll have one in place in one to five years.
What's driving the technology? The shortage of intensivists, specialists, and physicians willing to take call, for starters. Remote access brings doctors to patients regardless of where they happen to be. Another factor is that the technology itself is advancing so fast.
Remote units have high-definition displays, the ability to zoom right in and take high-resolution photos and high-quality videos, and digital stethoscopes that let docs listen just as well as—or even better than—they can in person.
Capabilities have also expanded rapidly. Healthcare organizations have access to faster and more reliable data networks, and abundant access to mobile devices.
And then there's that anecdotal evidence. Proponents say using technology to deliver care over a distance will improve access, ease physician shortages, create new revenue streams and increase volume for healthcare organizations by expanding market reach, and improve quality of care.
Still, there's that lingering lack of concrete evidence that remote care is significantly better than care delivered in person.
One new study that examined the impact of telemedicine ICU care on mortality and length of stay got a mixed answer to that question.
Researchers, who published their findings in the Archives of Internal Medicine in March, reviewed ICU outcome data from 60 years' worth of studies, including those that reported data on the primary outcomes of ICU and in-hospital mortality or on the secondary outcomes of ICU and hospital length of stay.
The researchers found that while telemedicine can impact ICU mortality and length of stay, it doesn't have the same impact on inpatient hospitalizations. The study suggests that organizations that are using the technology in the ICUs are on the right track.
Other studies are ongoing. A demonstration project at Wenatchee (WA) Valley Medical Center seeks to show that remote home monitoring can reduce hospitalizations, and, as a result, lower costs among patients with diabetes, congestive heart failure, and chronic obstructive pulmonary disease.
"The idea is that you would try to catch exacerbations at a milder stage before they require hospitalization," says WVMC CEO Peter Rutherford, MD.
In the first three years of the randomized trial, the organization met the program's goal of saving 5% net of costs. The number of clinic visits went up—and because patients had already been triaged by case managers, those visits were more productive. At the same time, hospitalizations and emergency room visits declined.
The study is currently in its second phase, which will expand screenings to include other disease states such as asthma and comorbidities such as depression.
Loyola University Medical Center implemented its telehealth program about four years ago as a way to increase after-hours coverage at its 14-bed pediatric ICU.
Clinicians, including rapid response teams, use the technology to evaluate patients and intervene in a timely manner wherever they are. About 75% of patients treated remotely are transferred to the ICU; doing so early is a best practice that lowers mortality rates among high-risk patients, Kathleen Webster, MD, director for pediatric critical care and the medical director for the pediatric ICU, told HealthLeaders Media.
"We went an entire year with no deaths in that group—and that's as low as I can go with the numbers," Webster says. "That tells us that we're doing a good job of seeing these patients early."
No doubt that zero is an impressive number. But as the field of telemedicine continues to emerge, so must research into its clinical effectiveness.
Since the Department of Health and Human Services released its proposed accountable care organization regulations last week, technology that enables data-sharing has suddenly become even more important than it has been since the first-stage meaningful use regulations were announced. And Health information exchanges are poised to play a key role—from aiding physician-hospital alignment to supporting medical home efforts to coordinating care among multiple healthcare providers to improving quality of care.
Doug Dietzman, executive director of the health information exchange Michigan health Connect, says his organization is ready to support its members, regardless of how the final rules turn out.
Although the organization currently only serves hospitals and health systems in Michigan, it plans to expand to other types of healthcare organizations and beyond the state border.
“We're … talking to the health plans, pharmacies, community health organizations, and others. We would expect that as we continue to grow that we'll have anybody and everybody who’s involved in the healthcare environment tied in,” he says.
And it’s not just about moving data—the organization will likely offer licensed software to its members. “The plan is to provide solutions,” he says. “[We’ll] provide the capabilities, either in moving the data or potentially even providing the solution components of an enabler or individual ACOs that spring up around hospitals [across state lines] or however they form. Michigan Health Connect itself won't be [an ACO] but it will have to be able to support and enable those members that need me to get the data where it needs to go or if they want to license software through [us].”
That model is an opportunity for HIEs to become self-sustaining when government funding inevitably dries up and should also make data-sharing easier for the ACOs of the future. The Michigan HIE is already there—it is 100% privately funded.
“We’ve accepted no public funding at the state or federal level. So all the conversations in Congress about defunding this or that don't bother me at all,” Dietzman says. “If I can build that kind of sustainability model, then as we add the other pieces we're on a solid footing.”
One business Michigan Health Connect won’t get into: selling EMRs. “There are so many options for a doctor to get an electronic medical record,” Dietzman says. “Our commitment is whatever system you choose, we'll meet you at the door and make sure you're connected.”
ACOs are going to require healthcare organizations to share information—a sticking point when it comes to competitors. But the Michigan program proves that it is possible to build that trust, Dietzman says.
“Trust is important,” he says. “In Michigan one of the things that has facilitated the growth is that folks have been in Michigan a long time and there was an element of trust already established. So I know you, you know me, and we know we can do the right thing here. We're going to have to do it anyway and so we can either do it the expensive way and compete or we can agree that in this area we're going to try and do whatever is most efficient—the right thing for the providers … So at the end of the day how do you do that if you don't get the data where it needs to go?”
From ink-jet printed skin grafts to mouse-grown human ears, research into tissue and organ engineering has an undeniable sci-fi quality to it—especially when biotech companies use phrases such as "tissue on demand."
But it's serious medicine that could have a profound impact on a wide range of disciplines, including cardiology, neurology, orthopedics, urology, and oncology, and many other specialties. Biotech could someday shorten wait lists for donor organs or eliminate organ rejection—since organs would be grown from the recipient's own cells.
It's also a serious market—one that a 2010 MedMarket Diligence report predicted will grow from $6.9 billion in 2009 to almost $32 billion by 2018.
I wish I could have been a fly on the wall the day that researchers at the Wake Forest Institute for Regenerative Medicine started talking about the project they're working on.
They use items you'd commonly find around the office—an inkjet printer, ink cartridges, and PowerPoint software. But instead of printing off sleep-inducing flow charts, the researchers fill the cartridges with cells and use the software to map out a shape.
Aided by a computer, the printer sprays skin cells directly onto a 3D scaffold to start the process of growing organs. They can also make skin—they use laser imaging to create a map of the burn site and then spray the healing cells directly onto the victim's wounds. No longer would burn victims have to sacrifice other areas of their bodies for grafting.
The skin printing technique is not yet ready for human subjects. But the technique has shown promise in animal studies. Mice with wounds similar to burn wounds that were treated with the bioprinting technique healed in three weeks compared to five weeks for control animals.
In another bioprinting project, researchers at Organovo, Inc., which focuses on regenerative medicine technology, created blood vessels from human cells that could someday be used for arterial grafts.
The National Institutes of Health is also funding research into bioprinting and other tissue and organ engineering techniques, with grants to develop structural scaffolds, organ-printing technologies, and grafting techniques. The Tissue Engineering Resource Center at Tufts University is funded by an NIH grant. Among other things, the center is working on scaffold designs to control stem cell differentiation and advanced bioreactor systems to impart controlled environmental stimuli to cells cultured on scaffolds.
You can read more about Wake Forest's bioprinting research in this month's issue of HealthLeaders magazine.
The patient portal of today has some neat features that are convenient for patients and save time and money for providers—online appointment scheduling and lab results for example. But what will the portal of the future look like?
Well, it might have a social media vibe, according to providers and experts I interviewed for a story on patient portals in this month's issue of HealthLeaders Magazine.
"The future of the patient portal is unlimited at this point," said Barbara Fahl-Watkins, administrator of the Heart & Vascular Center of Arizona. "I feel like we are just scratching the surface in finding new ways to communicate more thoroughly and efficiently with patients."
Eventually, portals could bring together virtual collaborative care teams that patients can access when it is convenient to them.
"In the future we will see the emergence of collaborative care plans where patients and doctors collaborate on disease management through patient portals," Brandon Savage, MD, chief medical officer at GE Healthcare IT, says in the article. "These interactions can be tied to collaborative care plans which ensure that best practices for quality, cost, and efficiency can be continuously brought to the patient not only at the point of care but throughout their daily life."
Smartphones and other small portable devices such as tablets have already changed the way consumers connect and communicate—in healthcare, patient and physician interaction will "likely occur much more with brief frequent interactions like Twitter than through prolonged infrequent interactions via a desktop computer," he says.
Providers often talk about the importance of access—reading patients when and where they are. Building patient portals that borrow from social media is one way to do that. OK, maybe patient portals will never be a daily destination such as Facebook or as addictive a chat-fest as Twitter. But perhaps borrowing some of the features of those sites will make patients more engaged in their care—and make it easier to provide them with the best care.
"In the future there will be more healthcare organizations using portals as a resource for patients to see valuable health information, but also as a way to increase patient loyalty and to grow market share," says Kim Gordon, integration solutions manager at Spectrum Health. "I see patient portals in healthcare moving from being used as a competitive advantage and patient satisfaction initiative to becoming something that a consumer of healthcare services demands and expects."
Hospitals might be cutting back on spending, but they're still shelling out for electronic health records, according to a recent HealthLeaders Media Intelligence Report on capital spending. Among survey respondents, 39% said EMR systems will receive the majority of capital funds in the coming year. Another 27% say most of their capital funds will go to clinical technology this year.
An investment in health information technology is an investment in growth, Greg Pagliuzza, the vice president and CFO of Trinity Regional Health System tells senior finance editor Karen Minich-Pourshadi in the report.
"A new facility does have a positive result with volumes coming back … but at the end of the day we have to ask, 'What is the ROI of building versus renovating?' " he says. "In terms of technology, I think we have to redefine how we look at growth in terms of delivery of care. It's not necessarily just about building or getting another CT scanner. We grow by drawing in a population that you didn't have previously … that's why EMR investment is growth, because you can take that patient and embed them in the system."
Beyond that, of course, are the financial rewards from the federal government for those healthcare organizations that meet meaningful use requirements. "When you look at the dollars that could be left on the table, it's a compelling reason to get this done," says Robin LaBonte, CFO at the 79-bed York Hospital.
Hospitals could use the money—nearly half (48%) said the economy has forced them to delay 2011 capital projects. And another 40% said some projects have been eliminated altogether. But again, IT projects seem mostly safe from the axe. We asked leaders to name the clinical initiatives they've put off or scaled back. Most (48%) answered none, while a handful cited CPOE and EMRs (15% each).
Finally, investing in HIT makes sense when you consider that 52% of healthcare leaders say improvement to quality of care is their leading priority when it comes to assessing a capital need (34% said they determine funding by replacement need and only 14% said return on investment is the primary factor in the decision.)
"Clinically, with all that's now being measured in terms of quality and patient satisfaction and how it will impact reimbursements, you really have to [invest in electronic medical records] just to keep up," LaBonte says.
Be sure to check the most recent HealthLeaders Media Intelligence Report, 2011 Capital Spend: EMR Dominates Budgets. Turn to page 8 to read Minich-Pourshadi's excellent analysis: "Tech Dominates Capital Budgets as Caution Continues."