healthcarereimagined

After a blizzard of hype surrounding the electronic health record (EHR), health professionals are now in full backlash mode against this complex new tool. They are rightly seen as a major cause of professional burnout among physicians and nurses: Clinicians are spending almost half their professional time typing, clicking, and checking boxes on electronic records. They can and must be made into useful, easy-to-use tools that liberate, rather than oppress, clinicians.

Performing several tasks, badly. The EHR is a lot more than merely an electronic version of the patient’s chart. It has also become the control panel for managing the clinical encounter through clinician order entry. Moreover, through billing and regulatory compliance, it has also become a focal point of quality-improvement efforts. While some of these efforts actually have improved quality and patient safety, many others served merely to “buff up the note” to make the clinician look good on “process” measures, and simply maximize billing.

Mashing up all these functions — charting, clinical ordering, billing/compliance and quality improvement — inside the EHR has been a disaster for the clinical user, in large part because the billing/compliance function has dominated. The pressure from angry physician users has produced a medieval solution: Hospital and clinics have hired tens of thousands of scribes literally to follow clinicians around and record their notes and orders into the EHR. Only in health care, it seems, could we find a way to “automate” that ended up adding staff and costs!

As bad as the regulatory and documentation requirements are, they are not the largest problem. The electronic systems hospitals have adopted at huge expense are fronted by user interfaces out of the mid-1990s: Windows 95-style screens and dropdown menus, data input by typing and navigation by point and click. These antiquated user interfaces are astonishingly difficult to navigate. Clinical information vital for care decisions is sometimes entombed dozens of clicks beneath the user-facing pages of the patient’s chart.

Paint a picture of the patient. For EHRs to become truly useful tools and liberate clinicians from the busywork, a revolution in usability is required. Care of the patient must become the EHR’s central function. At its center should be a portrait of the patient’s medical situation at the moment, including the diagnosis, major clinical risks and trajectory, and the specific problems the clinical team must resolve. This “uber-assessment” should be written in plain English and have a discrete character limit like those imposed by Twitter, forcing clinicians to tighten their assessment.

The patient portrait should be updated frequently, such as at a change in clinical shifts. Decision rules determining precisely who has responsibility for painting this portrait will be essential. In the inpatient setting, the main author may be a hospitalist, primary surgeon, or senior resident. In the outpatient setting, it’s likely to be the primary care physician or non-physician provider. While one individual should take the lead, this assessment should be curated collaboratively, a la Wikipedia.

This clinical portrait must become the rallying point of the team caring for the patient. To accomplish this, the EHR needs to become “groupware” for the clinical team, enabling continuous communication among team members. The patient portrait should function as the “wall” on which team members add their own observations of changes in the patient’s condition, actions they have taken, and questions they are trying to address. This group effort should convey an accurate picture (portrait plus updates) for new clinicians starting their shifts or joining the team as consultants.

The tests, medications or procedures ordered, and test results and monitoring system readings should all be added (automatically) to the patient’s chart. But here, too, major redesign is needed. In reimagining the patient’s chart, we need to modify today’s importing function, which encourages users indiscriminately to overwhelm the clinical narrative with mountains of extraneous data. The minute-by-minute team comments on the wall should erase within a day or two, like images in SnapChat, and not enter and complicate the permanent record.

Typing and point and click must go. Voice and gesture-based interfaces must replace the unsanitary and clunky keyboard and mouse as the method of building and interacting with the record. Both documenting the clinical encounter and ordering should be done by voice command, confirmed by screen touch. Orders should display both the major risks and cost of the tests or procedures ordered before the order can be confirmed. Several companies, including Google and Microsoft, are already piloting “digital” scribes that convert the core conversation between doctor and patient into a digital clinical note.

Moreover, interactive data visualization must replace the time-wasting click storm presently required to unearth patient data. Results of voice searches of the patient’s record should be available for display in the nursing station and the physicians’ ready room. It should also be presentable to patients on interactive white boards in patient rooms. Physicians should be able to say things like: “Show me Jeff’s glucose and creatinine values graphed back to the beginning of this hospital stay” or “Show me all of Bob’s abdominal CT scans performed pre- and postoperatively.” The physician should also be able to prescribe by voice command everything from a new medication to a programmed reminder to be delivered to the patient’s iPhone at regular intervals.

Population health data and research findings should also be available by voice command. For example, a doctor should be able to say: “Show me all the published data on the side-effect risks associated with use of pembrolizumab in lung cancer patients, ranked from highest to lowest,” or “Show me the prevalence of postoperative complications by type of complication in the past thousand patients who have had knee replacements in our health system, stratified by patient age.”

AI must make the clinical system smarter. EHRs already have rudimentary artificial intelligence (AI) systems to help with billing, coding, and regulatory compliance. But the primitive state of AI in EHRs is a major barrier to efficient care. Clinical record systems must become a lot smarter if clinical care is to predominate, in particular by reducing needless and duplicative documentation requirements. Revisiting Medicare payment policy, beginning with the absurdly detailed data requirements for Evaluation and Management visits (E&M), would be a great place to start.

The patient’s role should also be enhanced by the EHR and associated tools. Patients should be able to enter their history, medications, and family history remotely, reducing demands on the care team and its supporting cast. Patient data should also flow automatically from clinical laboratories, as well as data from instrumentation attached to the patient, directly to the record, without the need for human data entry.

Of course, a new clinical workflow will be needed to curate all of this patient-generated data and respond accordingly. It cannot be permitted to clutter the wall or be “mainlined” to the primary clinical team; rather, it must be prioritized according to patient risk/benefit and delivered via a workflow designed expressly for this purpose. AI algorithms must also be used to scrape from the EHR the information needed to assign acuity scores and suggest diagnoses that accurately reflect the patient’s current state.

Given how today’s clinical alert systems inundate frontline caregivers, it is unsurprising that most alerts are ignored. It is crucial that the EHR be able to prioritize alerts that address only immediate threats to the patient’s health in real time. Health care can learn a lot from the sensible rigor and discipline of the alert process in the airline cockpit. Clinical alerts should be presented in an easy-to-read, hard-to-ignore color-coded format. Similarly, hard stops — system-driven halts in medication or other therapies — must be intelligent; that is, they must be related to the present reality of the patient’s condition and limited to clinical actions that truly threaten the health or life of the patient.

From prisoners to advocates. The failure of EHRs thus far to achieve the goals of improving health care productivity, outcomes, and clinician satisfaction is the result both of immature technology and the failure of their architects to fully respect the complexity of converting the massive health care system from one way of doing work to another. Today, one can see a path to turning the EHR into a well-designed and useful partner to clinicians and patients in the care process. To do this, we must use AI, vastly improved data visualization, and modern interface design to improve usability. When this has been accomplished, we believe that clinicians will be converted from surly prisoners of poorly realized technology to advocates of the systems themselves and enthusiastic leaders of efforts to further improve them.

Article link: https://hbr.org/2018/03/to-combat-physician-burnout-and-improve-care-fix-the-electronic-health-record

Robert Wachter, MD, is chair of the Department of Medicine at the University of California, San Francisco and author of The Digital Doctor: Hope and Hype at the Dawn of Medicine’s Computer Age.

Last week, Bloomberg News told the story of three families without health insurance. We also asked readers to share their own stories as we spend the next year following people who are “risking it.”

The response was overwhelming. More than 3,000 people from across the U.S. filled out our questionnaire and shared their challenges, and how their decisions have affected their health and financial well-being.

Some can’t afford to insure their children. Others are seeking cheaper care abroad. Some older adults are counting down the years until they qualify for Medicare.

While these people are among the 27 million Americans who remain uncovered despite the large expansion of health insurance under the Affordable Care Act, their stories transcend politics, reflecting tough kitchen-table decisions about health care faced by many families.

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Whitney Whitman waited until her 7-year-old daughter had been sick for almost two weeks before taking her to the pediatrician for a visit that ended up costing $275. Her family of four in Bird Creek, Alaska, outside Anchorage, last had insurance in 2016.

When she looked for coverage last fall, the cheapest plan Whitman could find was $1,734 per month, with a deductible of $10,500 for the family. She splits her time between mental health counseling and mediating legal disputes, such as divorces. She made about $110,000 before taxes in 2016.

But student loans, mortgages on a home and a rental property, car payments and credit cards squeeze their budget — and health insurance is what got squeezed out.

She said her husband Jason probably broke his finger last year working on their house. “We just taped it up and kept going.”

They’ve done a lot of that. Jason’s knee injury and concussion also went untreated. Whitman would like to get an inhaler to alleviate seasonal asthma in the spring but says she’ll probably skip that, too. She’s thought about moving to Canada, which has universal health coverage, and has looked at jobs across the border.

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“We’re part of the population that’s healthy and isn’t paying into the system,” Whitman said. It’s a tradeoff she’s not entirely comfortable with, especially when her kids go skiing at the nearby Alyeska Resort, where her husband worked until recently.

“Every time my children do something remotely fun and risky, I’m envisioning in my head the horrible medical problems” that might ensue, she said. They wear helmets on the slopes, at least.

“I live in a constant state of fear,” Whitman said.

Tara Sullivan’s flu this winter was bad enough that her friends at the small law firm where she works offered to pay for her to see a doctor, since she doesn’t have insurance.

Sullivan, 58, declined their help, but she had a bad cough, tightness in her chest, fever and chills. So in February she went to the emergency room at Marietta Memorial Hospital, across the Ohio River from where she lives in Parkersburg, West Virginia.

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Her flu had turned into pneumonia, and filling prescriptions for antibiotics, steroids and an inhaler cost her about $250 at Walmart. She also got a $45 bill for a chest x-ray, which she hasn’t paid yet, and she isn’t sure what she might owe for the rest of the hospital visit.

Her job as a legal assistant pays her about $28,000 a year — $1,800 a month in take-home pay. Last fall she looked for an Obamacare plan, and saw premiums that would have cost her around $250 to $300 per month.

“We don’t have enough money to go out to eat, or take my grandchildren to the movies, much less pay for health insurance,” Sullivan said.

Behind on her gas bill, Sullivan got a disconnect notice in January. The money she would have used to pay it went to her prescriptions instead. The late-winter temperature in Parkersburg often drops into the teens overnight, well below freezing. She borrowed from a friend to make the utility payment, keeping the heat, hot water, and cooking gas on.

The “comprehensive health record” model is quite in vogue these days. Epic, in particular, is championing this model, which supplants existing EHR verbiage and integrates social determinants of health. “Most health systems know they have to go beyond their walls,” Epic CEO Judy Faulkner told Healthcare IT News. A number of other EMR vendors have followed Epic’s lead.

To date, however, most clinicians have yet to embrace this model, perhaps because they’re out of patience with the requirements imposed by EHRs. What’s more, the broader healthcare industry hasn’t reached a consensus on the subject. For example, a team of experts from UCSF argues that healthcare needs a “connected health record,” a much different animal than vendors like Epic are proposing.

The authors see today’s EHR as an “electronic file cabinet” which is poorly equipped to handle health activities and use cases such as shared care planning, genomics and personalized medicine, population health and public health, remote monitoring and sensors.

They contend that to create an interoperable healthcare ecosystem, we will need to move far beyond point-to-point, EHR-to-EHR connections. Instead, they suggest adding connections with patients and family caregivers, non-clinical providers such as school clinics for youth and community health centers. (They do agree with Faulkner that incorporating data on social determinants of health is important.)

Their connected health record ties more professionals together and adapts to new models of care. It would foster connections between primary care physicians, multiple specialists, hospitals, clinics, pharmacies, laboratories, public health registries and new models of care such as ACOs. It would be adaptive rather than reactive.

For example, if the patient at home with cancer gets a fever, her temperature data would be transmitted to her primary care physician, her oncologist, her home care nurse and family caregiver. The care plan would evolve based on the recommendations of team members, and the revised vision would be accessible automatically to the entire care team. “A static, allegedly comprehensive health record misses the dynamics of an interactive, learning health system,” the authors say.

All that being said, this model still appears to be at the vision stage. Perhaps given its backing, the comprehensive health record seems to be getting far more attention. And arguably, attempting to integrate a good deal more data on patients into an EHR could be beneficial.

However, both models are largely untested, and both beg the question of whether building more content on an EHR skeleton can lead to transformation. On the other hand, while the concept of a connected health record is attractive, my sense is that the components needed to this happen have not matured yet.

Ultimately, it will be clinicians who decide which model actually works for them, not vendors or abstract thinkers. Let’s see which model makes the most sense to them.

Posted on March 26, 2018 I Written By Anne Zieger

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Article link: https://www.emrandehr.com/2018/03/26/comprehensive-health-record-vs-connected-health-record

Maryann Mazer-Amirshahi, Pharm.D., M.D., M.P.H., and Erin R. Fox, Pharm.D.

• References

Genetic technology should be used for health treatments but not cosmetic changes such as eye or hair colour, a Royal Society survey of public opinion has found.

As Neils Bohr allegedly said, “It is hard to make predictions, especially about the future.”

By Prof Sir Venki Ramakrishnan
President, Royal Society

Indeed, Lord Kelvin’s 1895 declaration that “heavier-than-air flying machines are impossible” tends to loom in scientists’ minds when we are tempted to speculate about what technology might deliver.

However, there are times when the evidence is pretty clear. Developments in genetic technologies which have made them cheaper, quicker and easier to use could usher in a new age of biology.

We have been using conventional cross-breeding to select genetic variants of plants and animals for thousands of years.

Such selection by humans has resulted in the same species – dogs – being as variable as wolfhounds, terriers, greyhounds and Chihuahuas.

Similarly, cabbage, kale, kohlrabi, broccoli, cauliflower and brussels sprouts have all been bred from the same original plant.

However, by genetic technologies I mean the use of the tools of modern molecular biology to understand, make or adapt the genetic material in all living things.

Cure incurable diseases

Some genetic technologies have been with us a long time.

The insulin that keeps people with diabetes alive is a GM medicine. GM plants received a mixed reception from the public, but they now cover over a tenth of the world’s arable land.

Recently we had the case of baby Layla Richards who underwent an experimental gene therapy treatment at Great Ormond Street Hospital that cured her leukaemia.

To some extent the future is already with us.

As well as the examples above, researchers are working on ways to cure otherwise incurable diseases such as muscular dystrophy, on new treatments for other life-threatening diseases like leukaemia or conditions like arthritis.

It may soon become possible to correct a genetic disorder and prevent it from being passed on to future generations.

Potential downsides

A potentially very powerful method is the possible use of gene drives to modify organisms like mosquitoes to prevent them from spreading diseases such as malaria and the Zika virus.

Beyond human health, genetic technology could be used to remove invasive species.

New Zealand is already looking at this as a way of protecting native species in a country where a quarter of the unique bird species have been driven to extinction by invasive predators such as rats and possums.

When it comes to food, researchers are looking at genetic technologies to increase food production, for example modifying farmed salmon to require less food to grow, or preventing diseases that destroy crops. Researchers are also looking at ways to make food more nutritious and to develop crops that need less fertiliser or pesticides.

Scientists are exploring these possibilities but it is one thing to figure out what we can do and something else entirely to decide what we should do.

For those technologies that do work we need to know what the potential downsides might be and then it is up to all of us to decide whether any risks are worth taking, relative to the potential benefits.

In the case of Baby Layla there can be no guarantees about what the future may bring but all avenues of treatment had been exhausted.

It was an experimental treatment rather than part of a trial but it was a life and death situation and Layla is alive.

Ethical questions

There are many situations where people have legitimate concerns.

If we use gene drives to try and control disease, there are risks in the broader ecological consequences of reducing or even eliminating a species.

There is also a question of the ethics of eliminating one species for the benefit of another – ourselves.

With the genetic modification of plants, there are questions about who controls the technology.

These are questions that have a more general application and include technologies such as artificial intelligence and who owns our data but a lot of the public opposition to GM plants may be tied into the fact that the technology is often associated with big business.

For all the potential benefits that genetic technologies could have for human health there are also a host of ethical questions that need to be addressed.

There are questions about how far we should take it.

There is a great difference between altering a gene to remove the risk of inheriting a potentially fatal heart defect and altering a gene to change someone’s eye colour.

Would it be right to use genetics to make someone faster, stronger or smarter?

There are questions about who controls these decisions.

Would new treatments just be available to the richest people in society?

These are only a small number of the challenges and concerns people have and that is why we need to have a well-informed discussion.

We also live in a world where we face challenges that do not respect national borders but where priorities can vary greatly.

I grew up in India where many people do not have enough food to eat and where cancer survival rates are among the world’s worst.

But I have lived most of my life in the UK and US where priorities are different.

All of these perspectives need to be part of the conversation.

Decisions about how the technology should be developed should not be made by a small group of people, because the application of these technologies will affect us all.

If my prediction does not go the way of Lord Kelvin’s and we are on the verge of a new age of biology, it is one we need to go into with our eyes wide open so that science and technology – from which we have benefited so much from over the years – can continue to contribute to safer, healthier and happier lives.

Article link: http://www.bbc.co.uk/programmes/articles/4dppYMp0cJcpMbrhT6Tpfrs/a-new-age-of-biology