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![Choices
If [medicine] doesn’t act on its own to reduce the cost of
health care for the nation [medicine] will lose control
Choices are to lower the disease burden or be forced to
treat disease with fewer and fewer resources
Those that can adapt, provide improved health and
lower disease cost are going to thrive](https://image.slidesharecdn.com/familypracticeinformatics-v2-130313192932-phpapp02/75/Leveraging-Technology-at-the-Point-of-Care-19-2048.jpg)
Uploaded byDavid Voran
Leveraging Technology at the Point of Care
This document discusses leveraging healthcare technology to maximize efficiency at the point-of-care. It describes how younger providers sometimes struggle more with technology application than older providers. It also discusses seminal moments in computing and recent influencers, including how the rate of technological change is accelerating. The document advocates for preparing for the next healthcare inflection point by effectively using technology, which depends on willingness to change non-technology practices. It provides suggestions such as exploiting new user interfaces, embracing self-tracking apps, and changing workflows.
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Leveraging Technology at the Point of Care
- 1. Widescreen Test Pattern(16:9) Aspect Ratio Test (Should appear circular) 4x3 16x9
- 2. Leveraging Healthcare Technology MaximizingEfficiency At The Point-of-Care David Voran, MD Medical Director, Innovation Clinic Heartland Health [email protected]
- 3. Good fund ofknowledge but… Minimal “System” awareness Needed help being a part of the team Lacked skills to elicit patient engagement and participation Remedial training needed to use computers in front of patients Negative impact on productivity and career satisfaction
- 4. It Doesn’t JustHappen Younger providers have more difficulties applying technology than older providers
- 5. Seminal Moments DKay Clawson, MD “By the time you graduate from residency a large part of what you learned during medical school will be obsolete.” Gordon E. Moore the number of transistors on a chip will double approximately every two years Robert Metcalf Power of a network is proportional to the square of the number of nodes
- 6. Recent influencers Law of accelerating returns Illustrated by Moore’s and Metcalf’s laws PC’s will match the power of the human brain around 2020 Approaching singularity Culminate in the merger of biology and technology Transcend limitations of our biological bodies and brains No distinction between human and machine or between physical and virtual reality
- 7. Recent influencers Healthcarediagnostic instruments and Professor of Theoretical information moving out of the hospital to Physics at the City University clinics, homes and individuals of New York Significant future care will be virtual, multimedia and come to the patient Medicine will become personal rather than population based We will control our genetics
- 8. A Long TimeAgo … at KUMed
- 9. Accountable Care Organization The world changes … again
- 10. Heading into anew world Are we adequately prepared?
- 11. Agenda The nexthealthcare inflection point has started Effective use of technology will be a differentiator Suggest ways to take advantage of the next curve
- 12. Impending Inflection Point Wherewe change the vector
- 13. External Forces =Barriers Workforce shortages Economic vicissitudes Provider discontent Rate of change overwhelms adaptation resources Unsustainable practices Vendor “lock” Competitive nature of our society Security woes Conflicting rules and Foggy long term vision regulations
- 14. Growing Needs, DecliningResources Medicare Enrollment (Millions) 100 80 60 40 20 0 2010 2020 2030 2040 2050
- 15. Where are we?… Really Of 13 countries in recent study … 13th for low-birth weight % 13th for neonatal & infant mortality 11th for postnatal mortality 13th for years of potential life lost 11th for life expectancy @ 1 yrs (females), 12th (males) 10th for life expectancy @ 15 yrs (females ),12th (males) 10th for life expectancy @ 40 yrs (females), 9th (males) 7th for life expectancy @ 65 yrs (females), 7th (males) 3rd for life expectancy @ 80 yrs (females), 3rd (males) 10th for age adjusted mortality 225,000 iatrogenic deaths per year – 3rd leading cause of death Barbara Starflield, MD, MPH. JAMA July 26, 2000
- 16. We are theoutlier in just about any measure
- 17. “Unlike those ofalmost any other area we can think of, the dynamics of the medical marketplace seem to be such that the advance of technology has made medical care more expensive, not less.” Steven Brill Bitter Pill: Why Medical Bills Are Killing Us
- 18. Independent investments content, communication, collaboration and social platforms Couple with business applications Dennis Schmuland, Chief Health Strategy Officer, U.S. Health, February 7, 2013 MSDN Blog
- 19. Choices If [medicine]doesn’t act on its own to reduce the cost of health care for the nation [medicine] will lose control Choices are to lower the disease burden or be forced to treat disease with fewer and fewer resources Those that can adapt, provide improved health and lower disease cost are going to thrive
- 20. Effective use oftechnology… Depends heavily on willingness to change non-technology practices
- 22. Garbage In =Garbage Out Culture of data entry only No one measured on accuracy or completeness of data Mindlessly enter data without “updating” key elements Every chart replete with similar examples
- 24. Who’s Responsible? Every onepoints to someone else … … no one wants to pay anybody to be responsible
- 25. Focus on Data= Heavy IT Burden and … little use to us
- 26. Consequences Reconciled Unreconciled
- 27. Tech works bestwhen … Paper based policy and procedures are changed Workflow is modified Rethink who does what, where and when Connections made to the world Remember Metcalf’s law Goal of an EMR should be to know everything about the next NEW patient
- 28. Making headway (Easyto Hard) Putting pieces together from the easy to the hard
- 29. Hardware is lowhanging fruit Can do more in less time with more and larger screens
- 30. Exploit new userinterfaces Touch and getting rid of chairs ≈ 30 min/day
- 31.
- 32. Embrace Self TrackingApps Value add opportunity Chronic disease management Real-time remote monitoring Preventing visits and admissions Optimizing health Encourage competition, participation
- 33. Changing workflows isharder … but pays more Using technology pays Tech / Workflow Savings/Benefits Patient Portal & Direct messaging 4-8 hours of phone time per nurse/week >75% reduction in phone volumes/week per physician 30% reduction in electronic messages Nurse and physician using same work Simplifies training flow tools Reduces redundant data entry Less work for each person Improves completeness of information collection Increases patient involvement Increases transparency Large screens Exam room – Improved access to information Increased patient involvement Reduction in visit times? Nurses Improved information display 50% reduction in window manipulation Reduced prior auth time and frustration
- 35. Technology extends contact ChenLM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169(20):1866-
- 36. Patient Use ::Physician Use
- 37. IOM Workshop Advice Teach patients how to obtain and use their personal health information Teach consumers how to navigate the health system effectively Present patients with options and listen to their concerns and feedback Establish a connection and relationship with patients & their care givers Avoid jargon when presenting information to patients and caregivers Find new ways to listen to patients and families http://www.medpagetoday.com/PublicHealthPolicy/MedicalEducation/37539?utm_source=twitterfeed&utm_medium=twitter
- 38. Critical for MeaningfulUse From digitalization of data to active use by patients Patient engagement begins in the exam room Physicians must demonstrate this engagement
- 39. Technology extends reach Eliminates90 miles of driving Increases low cost “touches” Facilitates communication
- 40. Inexpensive robots areharder to drive so a good deal of practice is required. Even so bandwidth requirements limit use to facilities with decent Wi-Fi access points.
- 41. Bricks and Mortarmay be the hardest part of technology Redesigning Exam Rooms Facilitate point-of-care information sharing and education Encourage patient participation at many levels Computer in exam as much for the patient as it is for the physician Set’s stage of MU 3 patient engagement mandate
- 42. High Tech ExamRoom Suites
- 43. Solutions and Suggestions Tryingto connect the dots
- 44. Opportunities and Needs Cleaning up the data requires culture change Education plays a major role It’s going to fall to the physicians in the long run Maximizing current technologies Encourage innovation while in training Make time for and allow experimentation Incorporating these skills into training
- 45. Cleaning up theData Career opportunities for those who are retiring or starting out Eliminating redundant and conflicting data Inculcating a culture of accuracy & verification Reconciliation should be part of everyone’s job Discovering a work flow based on patient validation and attestation
- 46. Systems approach Learningas an integrated team Patients, Techs, Nurses, Physicians solving problems together A minute saved for one may lead to hours of work by others Understand cycle time (be a patient) Teach and understand financial implications of actions Average cost of dictation $20K/yr (don’t allow or do it) Always work from the patient’s perspective
- 47. Maximizing tech investment Almost every device can be used for a synchronous visit But very few are leveraging this – reimbursement barrier ACO environments eliminate this barrier Continually think of ways to eliminate logistical barrier Rounds could be conducted virtually Several times a day if not hourly Think low cost neighborhood clinics scattered throughout the city for primary and virtual specialty care
- 48. Recommendations EMR clean up as part of the medical school curriculum May go a long way to staunch the growth of corrupted data Help incorporate chronic disease management into each visit Group visits with physicians and care coordinators Practical EMR training at the point of care Piano bar, not recital Doesn’t come naturally and must be learned Develop a joint effort with the other residency programs to assure that every graduate is “certified” in at least 3 EMRs
- 49. KC Opportunities Numerous residencies History of cooperation Good variety of EMR vendors Provides diversity experience for residents Different models of care FFS, ACO and Employer based Google Fiber … a natural multiplier Cooperative rotation would provide graduates with tools needed to be productive in almost any career
- 50. Questions? …. some answers, Maybe
Editor's Notes
- #4 There’s no question medical school are turning out physicians with great medical skills and knowledge. However, when they finally graduate it becomes apparent that many of the graduates have very little awareness of the “system” around them. It seems they’ve not learned to be part collaborative team and lack the skills it takes to engage their patients and encourage their active participation in their health.While they all have computer skills they seem very hesitant in using those skills at the point of care in ways that draw patients in. These skills are not vendor dependent and apply to all operating systems. It often takes up to a year to learn these skills and in the interim they experience decrease satisfaction and productivity, no matter how it’s measured, suffers. It’s my contention that medical schools should be producing a “product” that is ready to roll when it hits the ground and doesn’t have to go through a trying period of re-education.
- #5 It’s one thing to know how to use a computer. It’s another thing to be able to use it medically. Yet another whole thing to use it effectively at the point of care with the patient.Not unlike the car analogy. It’s one thing to know how to drive a car. Another thing to be able to drive it through a busy city. But whole other thing to race that car competitively.It’s not so much about the technology but when and how to use the technology appropriately.
- #6 One of the most seminal or formative moments came during Dr. Clawson’s address to us new medical students during our matriculation. At that point I consciously decided to put most of my resources into learning how to access the latest information instead of cramming my head with factoids and knowledge that was forever changing.Gordon E. Moore, founder of Intel predicted the number of transistors on a chip will double every 2 years. I interpreted this to mean that I’d need to purchase new equipment every 2 years in order to stay current.Robert Metcalf, one of the “real” creators of the Internet and founder of 3Com, postulated that the power of a network is proportional to the number of nodes on a network. My interpretation? The more things I could connect a computer to, the more powerful and useful it became.So I spent the lion’s share of a year’s tuition for an IBM clone. My wife threatened to nail my gonads to the wall if that investment didn’t pay off. You can imagine my horror when I soon found out there was precious little in the way of software to help a 34 year old who was a decade past his undergraduate degree compete with the majority of highly motivated and intelligent classmates.Fortunately there was a cadre of other students in similar straights and we did manage to use those computers clinically.
- #7 What, then, is the Singularity? It’s a future period during which the pace of technological change will be so rapid, its impact so deep, that human life will be irreversibly transformed. Kurzweil, Ray (2005). The Singularity Is Near: When Humans Transcend Biology (Kindle Locations 361-362). Penguin. Kindle Edition. Culminate in the merger of biology and technologyTranscend limitations of our biological bodies and brainsNo distinction between human and machine or between physical and virtual realityKurzweil was the principal inventor of the first CCD flatbed scanner,[6] the first omni-font optical character recognition,[6] the first print-to-speech reading machine for the blind,[7] the first commercial text-to-speech synthesizer,[8] the first music synthesizer capable of recreating the grand piano and other orchestral instruments and the first commercially marketed large-vocabulary speech recognition.
- #9 Through a grant from UpJohn sponsored by the late Dr. James Price Doug (another medical student) and I set up an electronic bulletin board service in the Department of Family Medicine called DocTalk. Within a year they had expanded the service from one to 4 dedicated phone lines and were answering up to 1,000 posts from the lay public monthly. Many of these were from patients at KUMed who had been discharged but had many questions concerning their condition and/or their treatments. We medical students would do our best to answer them and when we couldn’t would grab their records and seek out faculty who had been involved in their care to help us answer their questions.This was long before the days of HIPAA so all of these questions were posted and answered publicly so everyone who logged into the various disease-related chat rooms could view and participate in the posts and responses.At times we felt we were learning more from answering these questions than we were from the medical textbooks as we had to not only read the questions but then answer them without using too much medical terminology forcing us to really understand our answers.
- #11 Art: http://www.socwall.com/desktop-wallpaper/36179/native-american-art-by-martin-grelle/
- #12 The events around us are putting us at another major medical inflection point, not unlike the effect of the Flexner report on which most of modern medical training is based.These events include the aforementioned acceleration of knowledge, processing power and connectivity but also payment reform stimulated by the unsustainable portion of the world’s budget current healthcare is taking.Will point out some of these quickly and then move on to how critically important it is that effective training in the use of technology at the point of care is going to be in the future and will provide some solutions
- #15 The current system will not be able to meet the needs of my generation as we poor into Medicare. A paradigm shift needs to occur in order for needs to be met. Need to do more for less, not more for more.http://www.medicalprogresstoday.com/projected_spending.png
- #17 No matter what measure US is an outlier
- #19 Technology encourages more procedures, not lessNo patient push back due to a disconnect between the receiver of services and payer of those services as well as improvement in safety with the newer technology
- #20 Healthcare is the only sector that hasn’t collaborated and made independent investments to connect their customers
- #21 Am convinced that while external pressures are dominating our conversations we should be taking proactive action to reduce the cost of health care rather than be forced to do so. We need to doing everything possible to lower the disease burden rather than working so hard to minimize symptoms after the factThose that can do these things will wind up thriving
- #22 It’s not simply a matter of purchasing and installing technology. Effective use of that technology is critical. The irony is that effective use of technology often has nothing to do with technology but everything to do with policies, procedures and human behavior.
- #23 Many are questioning whether we’re ready for innovation
- #24 As we begin to move out of getting the electronic infrastructure in place and are actually starting to use it to coordinate care we’re discovering a big problem. The data itself. We in medicine have never developed a culture of accuracy and validity. Banking, investing, retail or commercial have daily, weekly, monthly and yearly systems of validating data, running audits and balancing books. We in medicine just don’t have similar systems or cultures in place. No one “balances” the clinical books at the end of the day. We are measured on the volume of data entered rather than the accuracy, consistency and validity of data. All of our systems have places for structured and unstructured data. In the example above we have a structured problem list that downstream users and the information systems will use to report and manage subsequent care. Yet we have a dictated document containing crucial information that was never converted to the key structural data. Nowhere have I seen organizations with workflows containing people who validate the unstructured data and reconcile the structured with the unstructured. When asked why it’s often said that the individuals who might have the time to do this do not have the clinical expertise or knowledge to make those “decisions.” These people are in the positions they are because they were trained to make sure data was recorded and in the right places but not to worry about the content. Without content skills it’s hard to extract meaningful information from the data we record.In short, we have a big GIGO (Garbage In Garbage Out) problem that will need to be overcome in order to effectively move through and reap the rewards of the 2nd stage of Meaningful Use regulations.
- #25 Here’s a very specific example:A cardiologist’s note contains specific issues that need to be addressed in the patient being seen yet none of these appear in the patient’s problem list. This is because the cardiologist has chosen to dictate a short note and proceed to the next patient. When confronted this cardiologist remarked that “nobody pays me to do data entry” and it’s the “primary care physician’s job” to manage the patient.
- #26 It does take time to audit and reconcile the chart. Most of the technicians, clerical staff and others who in the past have organized and made sure the chart was complete and available (aka Medical Records or Health Information Management departments) will be the 1st to state they do not have the skills, knowledge or right to perform audits and reconciliation of the CONTENT but can only address whether or not something is present or absent in the right place. It is highly unlikely that organizations will demand or move clinical people who can do this into clerical positions throughout their organization. Another system will have to be put in place and right now the barrier is that no one is willing to pay clinical people to manage clinical information.
- #27 Evolving into an Agile Data InfrastructurePosted by lfreeman Jun 20, 2012It is becoming clear that we are reaching a collective inflection point where data growth either becomes an overwhelming burden to IT; or becomes a fuel to propel business innovation. Successfully moving beyond the inflection point requires a new way of thinking, and a new data infrastructure that supports historic growth levels while containing costs and avoiding complexity.For the purpose of this blog, however, we’ll take a higher level view. Beyond the specific technologies; Data ONTAP 8 and OnCommand 5 are the flagships of NetApp’s agile data infrastructure. This single-platform approach is critical to attaining agility for a several reasons. First, with a single architecture embedded within a group of storage arrays, all the arrays speak a common language and communicate seamlessly, without translation. The storage arrays within the agile infrastructure have exactly the same set of capabilities, and can execute these capabilities in unison. This is simply not possible in an infrastructure with disparate storage arrays using different architectures with dissimilar capabilities.Next, a single architecture means that administrators can “learn it once” as their data infrastructures grow from terabytes to petabytes – resulting in operational simplicity. Storage administrators become agile themselves as their learned activities allow them to become adept at managing ever-larger storage pools. With agility, monumental data growth is not destined to lead to monumental complexity.Finally, a single architecture provides a standardized protocol between the physical storage layer and the data management layer of the infrastructure – simplifying the design of data management API’s. This leads to an application/storage ecosystem that is efficient, and more importantly - adaptable. Diverse workloads with varying performance and capacity requirements can co-exist within the same infrastructure.
- #31 Productivity is proportional to screen real estate.
- #32 Large, multi-input all-in-one PC’s are inexpensive and make better desktops with less footprint than portable notebooks. By raising the work environment to counter level, adding touch and removing chairs is saving a total of around 30 minutes a day in lost productivity, decreased overuse symptoms, mproved fitness and lower stress levels
- #33 Leverage input and inexpensive off-the-shelf devices. Touch and large screens pull patients in and allow them to participate in the documentation. Don’t need a lot of specialty equipment. Total room investments are less than $2,500.
- #34 Cannot say enough about encouraging patients to use apps and volunteer to participate in their journey but also downloading and using the app.
- #36 Study and simplify each step of the way by using the simple fact that a patient’s chart can be accessed by multiple people at the same time. Try working in parallel instead of serially.
- #37 Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169(20):1866-1872. Much of our practice of medicine is passive in that we wait until a patient shows up at the door and then are in a rush to:Catch up, having to update our records with everything that happened in the interval between the last visit for established patients and populating the entire chart for new patientsGather information about an acute problemDiagnose, document and do all of the things necessary for billingAll of this in an average 15 minute visit. This approach stems from paper based work flows in which there was only one chart and it wasn’t available to the many people who “touch” the patient throughout the year including the patient.We’re not leveraging the many days of inactivity between visits nor are we using the improved access of electronic medical records to constantly keep the chart updated and intervene actively between face-to-face encounters that digitalization enables.
- #38 Patient participation in a portal is very dependent on physicians. If the physicians use the computer and other technology in the presence of a patient there is a very good likelihood of enrollment and use. On the other hand if the physician never uses the computer or demonstrates use of technology then there is very little likelihood of patient engagement.Initiative is very dependent on physicians (3% - 63% variability)
- #40 Recent legislation and regulations are encouraging healthcare organizations to use their systems in a meaningful way instead of treating them as digitalized paper. It’s one thing to own a car. It’s another thing to actually use it to get around. It’s yet another whole thing to make sure the care is being used all of the time instead of just by one person. This notion of using electronic systems outside the context of a face-to-face encounter and begin managing a patient’s disease in between visits to improve a patients overall health.No one would suggest that any meaningful response to a treatment plan could be made without the patient taking an initiative. The patient must be involved in the management of health. In order for the patient to be an integral part of their health they must be engaged. Engagement begins in the exam room and then spreads to every encounter with those involved in the patient’s care at every step of the way.The government’s regulations are unfolding in a way mandates participants to demonstrate they are effectively using their systems to engage their patients in a 3 step process. Most participants have accomplished or completing the 1st infrastructure stage and are beginning now to use those systems to better coordinate care across the continuum of care. The final 3rd stage will require that our patients are also using the system not unlike most of us bank, shop and invest on line.
- #42 It takes some skill in order to get where you need to be. Practice makes perfect.
- #43 We need to get away from the jail-cell exam room approach
- #44 Cerner Healthe Clinic and Exam suite
- #46 Need to begin teaching and demonstrating to students and residents Encourage, don’t discourage, use of new technologies in the exam rooms and connecting with patientsTrain, train, train
- #51 What about creating a program where Kansas City graduates become known for their ability to hit the ground running?