Albert Villarin, MD FACEP, CMIO & Associate CIO, Director, Quality Analytics, Staten Island University Hospital, Northwell Health Network
Progress continues across all healthcare providing innovations and enhancements of care delivery. Two disparate drivers, innovation and policy, remain separated in function and poorly adopted by clinicians. Computer automation of clinical workflows, voice activation reducing the keyboard burden, Internet-of-Things (IoT) integrating cloud analytics, telehealth and population health initiatives providing growth and oversight of the majority of healthy patients should bring necessary improvements for clinicians. However, a current and persistent rift exists between meaningful use policy mandates and healthcare innovation creating clinical end-user frustrations, and overall reduction of efficient care-delivery. The majority of a decade of national information systems department budgets was aligned to successfully deploy meaningful use electronic medical records. During the same period, EMR vendor business market drivers designed poorly integrated graphic-use-interfaces (GUIs) to abstract data from the clinical encounter. The expectations of federal legislators–to collect ‘meaningful use data’—have never been equaled by the advancements of EMR vendors to support such an extensive level of documentation. As clinicians struggled to learn functions of new EMRs in clinical practice, an obvious dichotomy has emerged. No longer could clinicians focus on patient care interactions, reducing both throughput efficiency and patient experience scores. Without fully understanding clinical workflows and impact of continually required federal healthcare policy, EMR designers failed to integrate EMR enhancements to improve clinicians’ adoption or live clinical evidence-based practices required a the time of care delivery.
"Orders outside the realm of evidence would create an alert and require special reasoning entered by the clinician"
Hospital networks struggle to provide enhancements due to budgetary reductions, competitive financial requirements both within and external to their facilities. The conflagration of these financial pressures from new healthcare policy payment reductions, and difficulty by EMR vendors to provide facile alignments with rapid hardware and software innovations created an overall negative healthcare experience for all participants: patient, clinician, and administrator. The patients lose trust with their caregiver since the EMR now removes a vital private human element during their visit. Due to the combination of clinical throughput inefficiencies and lessening of patient experience scores, administrators now must create new processes and initiatives to enhance the hospitality environments across our healthcare domain. Healthcare as an industry, unlike airlines, banking, automotive, and hotel-hospitality, has removed itself from the caring and focused on the health of patients merely as a data points–such data managed for a population; financial directors planning length of stay expectations; clinicians delivering care more remotely; and patients accessing care through an application on their smartphone.
In 2016, healthcare networks reported significant profit reductions due to a combination of admission and insurance payment disincentives, unexpected and unbudgeted costs of lengthy EMR implementations which fail to recapture pre-deployment payments and profitability. Forcing clinicians to change a lifetime of clinical practice, within a year of migration to ineffectively designed EMRs lacking rapid documentation tools, poorly aligns with cutting edge innovation and clinician satisfaction. In all other industries, the business product–an airplane, a banking workflow, an automobile, a new luxury hotel–are designed to the expectations of their customer. Ultimately, these industries respect customer end-users by designing, testing, and innovating their products with an expert–professional pilot, financial consultant, professional driver, experienced interior designer. The end products of modern EMRs–created a decade ago—have only begun to ‘test drive’ their products using real clinicians and provide changes to enhance the graphic user experience. Vendors must appreciate and respect the critical proposal that their EMR tools, just like the stethoscope era scalpel, can never impede the art of medicine. Healthcare vendors have reduced the clinician’s ability to deliver efficient care through poorly designed EMRs. Such poor documentation designs also stifle network expansion, profitability, and cost-reduction since reductions in insurance reimbursement are uniquely affected by inadequately designed clinical care delivery tools.
Future State–Social technological advancements, such as speech recognition, wearable technologies, and unification of information portals onto smartphones have become ubiquitous. Healthcare must align itself to current innovations and securely access the Internet-of-Things (IoT). Healthcare advances with enhanced interoperability platforms such as FHIR, real-time clinical dashboards, and cloud-based analytics are all available to unify the clinical experience for both patient and clinician. In all three hospital areas there will be growth in adoption and efficiencies as we move from meaningful use to clinician directed development and policy. .
For clinicians, voice command integration will allow documentation, order entry, EMR content navigation and data retrieval more efficiently and accurately. Evidence-based clinical rules will be directly coded within all EMR interactions continuously monitoring live data and will immediately respond to changes in patient information. Such evidence-based alignment with EMR workflows will reduce unnecessary orders and length of stay plus improve care delivery by preventing practitioner bias. Orders outside the realm of evidence would create an alert and require special reasoning entered by the clinician. Any repetitive clinical processes, workflows, or procedures should be created in the EMR by clinical informaticists specifically trained in the clinical discipline. EMR vendor engineers should collaborate with specialized clinicians to develop clinically specific graphic user interfaces and workflows aligned to care. For patients, advancing their healthcare portal smartphone or computer experiences with secured access to all their clinical data and appointment scheduling functions, reminders and evidence-based educational materials would provide a common, recognizable, and effective process to retain patients within the healthcare network. For administrators, clinical directors and quality analysts, all clinical data would be available at any time across the healthcare continuum via a healthcare information exchange. As evidence based rules monitor minute to minute clinical changes, cloud based data warehousing algorithms will be able to continuously evaluate and eventually predict outcomes based on global data aggregation.
The new ‘care delivery disruption’ which IoT creates in automating workflows, data aggregation for analysis, and optimizing resources to deliver better care will provide several advantages for healthcare organizations and care teams. With real time patient monitoring, care plans can be adjusted on the fly, decreasing office visits and potentially avoiding readmissions. Physicians’ treatment plans and subsequent outcomes will be improved by having data that can make diagnosing patients easier and more accurate, and help guide treatment in ways that are effective and timely. Care coordinators and population health workers will have additional tools to track patients and intervene where appropriate thereby avoiding patients becoming at risk for further complications. In order to monitor health of a population, wearable technologies can prevent clinic visits and filter patients move efficiently. Patients and their families will also have a greater sense of well-being knowing that they or their loved ones are continuously monitored for status changes and that low impact interventions can be quickly implemented, thereby enhancing the patient experience. Genetically prescribed precision-medicine will bring about a new era of advanced medicine. Clinicians will target disease diagnoses and prevention through integration of new EMRs, evidence based protocols and genetics evaluation. Tele-health visits will be enhanced with the availability of real time clinical data, while also providing a lower-cost alternative to patients with mobility or transportation issues. Finally, many hospitals deploy some form of IoT connectivity such as RTLS identification badge sensors used for patient or clinicians location tracking or RFID tags for asset tracking, business analytics and service maintenance.