Last year’s AMDIS Fall Symposium focused on the Innovation Revolution, with speakers from a variety of organizations pushing the envelope when it comes to care quality, patient engagement, information exchange and new ways of delivering care.
For example, continuous care improves patient engagement with the healthcare system and improves both clinical outcomes and efficiency, said Kamal Jethwani, MD, MPH, head of the research and program evaluation initiatives at the Center for Connected Health in Boston.
He shared an example using remote monitoring for heart failure. Patients both with and without heart failure dropped their rate of hospitalization by 50 percent. “By monitoring heart rate and blood pressure, we also see drops in falls, urinary tract infections, chronic obstructive pulmonary disease and more. We realized that when patients start monitoring themselves for anything, they make healthier choices across the board. There are very few things in medicine that can do that.” The monitoring even increased patients’ lifespan.
More personalized care is “simple and extremely difficult,” said Robert Havasy, MS, corporate team lead for product and technology development, also at the Center for Connected Health. “Almost all interventions require data but knowledge does not equal motivation.” He said ability matters more than motivation when it comes to taking action. “Behavior is the intersection of ability and motivation. If you are having trouble getting someone to do something, it’s better to make it easier for them to do it than to give them more motivation.”
To get something to stick, the technology has to disappear. “It seems simple but, in fact, is very complex. We can’t just reach patients. We have to engage them.”
New tech easing bottlenecks
Wearables and other devices are improving efficiency of care to help ease stressed emergency department (ED) resources while making an impact on physician-patient relationships, said Steve Horng, MD, MMSc, assistant director of emergency informatics at Beth Israel Deaconess Medical Center in Boston.
The number of ED visits is rising at “an exponential rate,” Horng said. And, the aging population coincides with decreasing capacity but innovative technologies can change how clinicians use their limited time.
Beth Israel’s first foray into portal computing involved workstations on wheels (WoWs). Bedside registration is one of the most impactful changes the medical center has made. Three studies showed a 15-27 minute difference in door-to-doc time, and reduced wait times meant improved patient satisfaction, he said.
They wanted to find a way to accomplish the same using a smaller device and found that “using iPads, users spent 38 minutes less time on computers and logged in an average of five fewer times,” said Horng.
In another project, the medical center disseminated iPads to select ED patients who were experiencing pain (and were not psychotic nor had previous pain medication-seeking behavior). These patients used the iPads to surf the web and download apps, and the device would periodically question the patients on their pain level and whether they needed pain medication.
The intervention did not lead to a reduction in reported pain levels, but it did offload some of the nurses’ work as patients needing medications were immediately identified by the devices.
Implementation of Google Glass in the ED has led to more efficiency by providing physician access to the tracking board, medication orders, problems lists and the integrated PACS.
CDS as GPS
Physicians can’t know everything or be expected to process countless pieces of information at the drop of a hat, said Jonathan Teich, MD, PhD, CMIO for Elsevier and an emergency room physician at Boston’s Brigham and Women’s Hospital.
“CDS is giving you the right information at the right time.” Good decision support should work the same way a global positioning system (GPS) in a car works, Teich said. The technology that goes into making GPS work is sophisticated and intricate, but the end result of all that technology is the communication of a simple piece of information—“turn right” or “turn left”—relevant to the time it’s needed.
“Something like this is implementable, easy to use, valuable and cost effective,” Teich said. “That’s why GPS is everywhere, and CDS needs to get to that point.”
Which isn’t to say that we haven’t seen evidence of good CDS. As Teich pointed out, there have been many studies showing the value of CDS,
“so we know that if CDS is well designed and well implemented it does wonders.”
Much of his work at Elsevier involves knowledge and filtered reference, Teich said, adding that Elsevier puts out about seven million pages of distinct information every year. Some of what Teich is working on now asks whether all of this medical information can be taken and encoded. For example, if Teich can take information nuggets, like “chest X-ray is the best diagnostic test for pneumonia, but not for a pregnant patient” and put it into a knowledge base, “the next time something changes I don’t have to change the entire reference, I just have to change that particular nugget and then I can make them available as services.”
Is the concept of an innovation center outmoded? That was the idea posed by Sachin Jain, MD, MBA, chief medical information and innovation officer at Merck and Company. Innovation centers “take people off the hook to innovate every day in their jobs.” While these centers can focus on new ideas, they take “what should be the work of many and make it the work of the few.”
Innovation activities should be organized around problems not the big concept of innovation. This “orients the energy on the right things. I urge a high level of specificity.” The right talent “raises the bar, raises ambition and builds credibility.”
Measurement matters, but only the right measures. So much success is intangible, Jain said. “By focusing too much on what can be measured, we sometimes lose out on some of the impact that’s more difficult to measure.” He advised the audience to lay out a plan for measuring but to get early buy-in for intangible benefits because they “often are a lot more important.”
Transforming to symmetric information
The fundamental nature of the relationship between physician and patient is inevitably changing, and healthcare providers need to get on board with that change, because the “train is leaving the station,” said Danny Sands, MD, MPH, chief medical officer at both Conversa Health and Kinergy Health.
Sands has long partnered with patient engagement activist Dave deBronkart, also known as “e-patient Dave.” deBronkart came to Sands with stage 4 kidney cancer, researched his disease, sought out other patients in similar situations, and showed how informed and engaged in their own healthcare patients can be.
We are seeing a shift from patients being passive recipients of information to being active partners in their healthcare, from paternalism to participation, and from something that is more than a simple patient-physician relationship, but is a consumer-provider relationship as well.
All of this really means that physicians and patients are becoming collaborators, with each bringing something to the table. Patients have expertise in being patients and know themselves better than physicians do, Sands pointed out, while physicians obviously have expertise in healthcare.
Participatory medicine is a new paradigm and will take getting used to, he said. It will end up transforming both the patient and clinical experience, he argued, and promises to improve quality, reduce costs and increase satisfaction.
Innovation within commercial systems
According to Adam Wright, PhD, associate research scientist in the Division of General Internal Medicine and Primary Care at Brigham and Women’s Hospital (BWH) in Boston, and senior medical informatician in the Clinical and Quality Analysis Department at Partners HealthCare, the feeling at BWH over the years was that there was really no need to consider transitioning to a commercial system because nothing could top its home-grown system.
Once BWH made the decision to go with Epic, Wright asked himself how he would do informatics research and innovation in the new system. Over time, as he learned more about Epic, he has become “increasingly optimistic” that there are “neat” ways to do innovation within the Epic system.
Wright said that BWH and Partners have taken several steps—beyond getting software in place—to encourage innovation within the Epic system.
The first step, he said, was creating an innovation council as one of the four councils governing the implementation of Epic. “What was neat to me was that innovation was one of the top-level committees or principles, so that at least from the leadership there was a serious desire to continue to innovate within the system,” Wright said.
Among the recommendations that have come out of the committee was creating
a dedicated innovation copy of Epic—a separate copy of Epic that will allow innovators who want to prototype a new idea in the system to build the idea out and test it in a laboratory setting in real time. “This will sort of prove there is value in it before we decide to make an investment to move it into our main environment,” Wright said. “We think that will be a tool that will be helpful for allowing a sandbox for innovation without interfering with the very aggressive timeline we have to do the production and implementation of Epic.”
“We’ve also created a set of areas we call fertile fields,” Wright said. “These are areas where we think there are significant opportunities to innovate. We are trying to create a zone where people who are interested in innovating but may not have all the technical skills needed to do an innovation could work.” For example, Wright explained, if a nurse or physician comes forward with a new paradigm for clinical documentation, he or she could approach this fertile field management group and get the technical and analytics resource support necessary to develop this new innovation.
Small projects can be big
In the future, doctors will see fewer patients but take care of more patients as part of a larger care team—in a “really high value, high quality way,” said Lyle Berkowitz, MD, associate chief medical officer of innovation at Northwestern Memorial Hospital in Chicago.
Berkowitz advised that “it’s okay to start small—little bets can equal big wins.” At his own organization, he created a small program that involved lending iPads to patients. Patients checked out the five iPads for a few hours or a few days. They loved them, Berkowitz reported, using them for a variety of purposes with the No. 1 use being videoconferencing.
The organization also garnered valuable lessons such as finding that their network was sorely lacking for videoconferencing. They were able to improve that to handle a larger volume. “It’s okay to start small. You can learn a lot,” he said.
Berkowitz recommended that healthcare organizations “listen to and observe the front line. Your organization has much of the knowledge you need. Just talk to them.”