2 Placing patients at the center of patient-centered care: a healthcare provider system perspective of a powerful new technology-enabled “language”
The critical role of secure, two-way patient/clinician connectivity tools in the strategic design, planning and growth of provider organizations
Abstract: Technology-savvy patients demand online access and convenience in practically every purchase, transaction and decision they make.[1] By including secure, technology-based two-way patient connectivity tools as a core component of their strategic equation, many forward-thinking healthcare provider organizations are working to satisfy consumer demand and use the information patients enter for and about themselves to design services that will more efficiently align clinician skills, facilities and locations with patient needs and preferences in ways that will increase outcomes quality and service affordability. The data generated through online systems that provide self-service insurance and co-payment management, pre-procedure questionnaires aligned to clinician-designed, technology-enabled care plans, demographically and geographically detailed maintenance capabilities, patient satisfaction surveys, and the ability to monitor patient recovery as part of readmission and avoidable complication reduction initiatives, can all be used to focus the perspective and guide the thinking of provider organization leadership as they work to meet the challenges of the coming, change-intensive years.[2] Building healthcare delivery systems that will remain competitive over the long-term requires strategic decision-making skills based on both experience and accurate, actionable information. Including the voice of the patient in this process will empower provider organizations to clearly understand the populations they serve as well as envision and build better versions of themselves that will meet and potentially exceed the growing demands of an aging population.[3]
2.1 Introduction
In many ways, written language may represent the single most important technology ever developed by human beings because it embodies three critical concepts that fundamentally transformed the way people understand themselves and their place in the world. The first of these concepts is the idea that a sound or symbol can represent something other than itself.[4] This transcendent leap of creativity resulted in the construction of words, the world’s first bytes of discrete data. Organizing words according to a commonly understood set of rules, or standards, and thereby capturing and transmitting ideas that are far more complex than any of the construct’s component parts, is the second of our critical concepts. And the third is that writing these data streams down on some type of a medium allows them to be saved for, and used by, other people in other places and at other times. This simple paradigm of organizing discrete packets of data into information that is then recorded in a way that makes it accessible and useful to others changed, quite literally, everything – from the way societies could be organized to the skills and aptitudes individuals and groups needed to compete and succeed.[5]
When examined through a lens of core principles, the ongoing digitization of the modern healthcare industry can be seen to contain precisely the same components –discrete data capture, data organization and meaning, and standards-based information storage and exchange – that made language’s impact so all-encompassing and profound. Every day, all around us, incredible amounts of data (much like the unarticulated thoughts of pre-articulate people were once trapped inside their own, individual brains) is moving from the dark paper prison of the traditional medical chart into the bright light of a new day as the discrete, accessible raw material of tomorrow’s new knowledge. Clinicians are more effectively connected. Increasingly integrated workflows and treatment interventions are expressed as a part of ongoing cycles of coordinated care. Additionally, demographic and outcomes data are beginning to extend the reach of medical researchers more deeply,[6] and more quickly, into a richly detailed virtual reflection of reality that begins with the dynamic, real-time documentation clinicians perform directly at the point of care.
For the leaders of healthcare provider organizations, the stories that today’s health information technology-based systems can tell about the workings of their organizations, both as clinical environments and as businesses, are also changing, quite literally, everything – from how human skills and physical resources are allocated and distributed, to the transparency and reporting expectations of payers and other contractors, to what it actually means for a patient to “see” a doctor. Medicine has always been a “knowledge business”, and in today’s increasingly digital medical practice environment, information technology-enabled tools are a foundational component of the language the knowledgeable speak.[7]
But the defining purpose of language is, and will always be, exchange: of observations, ideas and experience. And even as technology-enabled tools are making it easier for clinicians to capture and collaborate through stories of ever-increasing complexity, the patients about whom these stories are written are beginning to use aspects of these same systems to more actively participate in the particulars of their care – and they are doing it by writing portions of their own stories themselves. For these patients, secure information technology connectivity is the medium through which they are making their voices heard from the places where we all spend the vast majority of our time; not in a doctor’s office, but at home, at work, and at play. [8] And while other industries might gather information about their customers in the hope of better understanding their behavior for the purpose of increasing sales, the goal of every healthcare professional is, as it has always been, to deliver high quality patient care.
So each and every day, healthcare providers across the country are using the emerging language of technology-based connectivity to more thoroughly understand the status and needs of their patients based, in part, on information those patients enter for, and about themselves.[9] Physicians and patients are using their visit time to add depth and color to the health-related stories they are writing together. In addition, leaders of provider organizations who are actively navigating the increasingly complex intricacies of today’s rapidly changing healthcare environment are aggregating these patient stories into knowledge-rich narratives that they can then use to inform the decisions they make about the forms and functions of their organizations in a nation that is moving from a volume-based to a value-based model of care delivery. [10]
To illustrate the real-world, transformative impact of two-way, technology-enabled provider/patient connectivity on care quality and the ability of provider organizations to remain viable and competitive in an increasingly demanding marketplace, the following story relates the experiences of a fictional patient moving through an equally fictitious healthcare delivery system. This fictitious provider system is intended to depict the high-level capabilities (not actual vendor-developed or regulator-approved products or systems) of an organization that uses the language of integrated information technology-enabled tools to connect its employed and aligned caregivers, its facilities and locations, and its processes and services to meet the needs of its patients as individuals and, through integrated analytic capabilities, its various regional patient populations. As events progress, we will pause to discuss some of the transformative features that make this story possible; many of them are based, in part, on actual innovations that are presently functioning components of Cleveland Clinic’s “patients first” integrated care model. Finally, we conclude our discussion with a look forward to an envisioned national healthcare environment that embodies some of the improvements that technology-enhanced patient/provider connectivity may help us achieve.
2.2 One patient’s story
2.2.1 The emergency department
Michael Smith is a healthy, forty-four year old man who has a passion for staying active. He loves to push himself in any competitive sport, especially cross-country cycling. With spring in the air, he is spending his Sunday afternoon ramping up his outdoor activities with a pick-up game of basketball at the local park. Late in the second half of the fast-paced game, he takes a quick corner pass, sees an open lane and charges in for a layup. Stretching over his defender’s head he rolls the ball off his fingertips to score, but as he is coming down he clips the defender’s shoulder, twists, comes down hard on his right leg, feels the knee buckle and lands in a heap on the concrete. Falls are nothing new for Mike, who counts the occasional bump and bruise as the price of admission for the games he loves to play, but from the amount of pain blasting up his leg he knows that, whatever he did to his knee, it was bad. By the time he hops over to a bench the knee is already swelling, and it keeps swelling, quite impressively, as one of his buddies drives him to the closest emergency department (ED), which happens to be part of one of the three large healthcare provider systems serving the region.
Since Mike Smith has been treated by clinicians employed by the health system in the past, the attending physician uses the integrated electronic medical record (EMR) system that links every caregiver in every one of the system’s eleven regional hospitals and fourteen community family health center locations to update his demographic information, including his active medications, medication allergies and other pertinent details before going on to document the specifics of the encounter. Through the EMR, the ED physician also orders an X-ray of his knee and, because the system can display the images associated with a study’s results inside an open encounter, goes on to review the results with the patient, right there in the exam room.
Turning the computer screen to make the actual X-ray pictures part of his condition education, the doctor says, “Well, Mike, you obviously don’t have any broken bones, which is good. But given the amount of pain you’re experiencing, and that swelling, I’d say the chances are good that you have some soft tissue damage. Since an X-ray doesn’t really capture that kind of injury, I think it would be a good idea for you to follow-up with an orthopedic specialist, who will probably want you to have an MRI. Until then, we’ll get you some crutches and send you home. Keep the leg elevated, and ice the knee to start getting that swelling down. I’ll order an anti-inflammatory and some pain medication to help keep you comfortable overnight. Do you still use the pharmacy on Woodland Drive?”
Mike indicates that yes, he does.
“Okay”, the doctor says, pressing “enter” on his keyboard and using the EMR to transmit the ePrescriptions to the patient’s pharmacy of choice. “You can pick those up on your way home”.
A few minutes later, Mike Smith is standing – somewhat awkwardly – on his new crutches when the person at the discharge desk looks at a computer screen and says, “I notice that the doctor recommended a follow-up appointment with an orthopedic specialist. Would you like me to schedule that for you now?”
“Yes, please”, Mike replies, and after a few seconds during which the hospital employee uses the integrated scheduling feature of the health system’s EMR to do an appropriate provider availability search based on the information documented by the attending ED physician, she surprises him with the choices she is able to offer.
“I want to make sure that you get to the right specialist, in the right location”, she says, her eyes scanning the illuminated screen. “So, you could see one of our specialty staff physicians, but the first available appointment for tomorrow is all the way on the other side of town. Or, okay, here’s an orthopedic specialist who isn’t on our staff but who is a member of our Quality Choice community physician partnership program. He’s an excellent doctor, and he’s got a spot available tomorrow at ten a.m. He’s located very close to where you live; so, what would you like to do?”
Mike chooses the Quality Choice physician, and the scheduler books the appointment, which automatically sends a verification to his health system-provided personal health profile account and, at the same time, activates a timed reminder that will send him an alert through the app on his smartphone one hour before he is scheduled to arrive at his new physician’s office.
Then, with his follow-up appointment scheduled, his ED after-visit summary downloaded to the “upcoming appointments” section of his personal health profile, and his encounter closed, Mike heads for home, stopping at his local pharmacy, where his medications are waiting to be picked up.
2.2.2 Transformative Features: Connectivity, Care Continuity, Patient Choice
Immediately following his injury, Mike Smith enters an emergency department that happens to be close to the site of his accident. But even though he did not actively choose this location, he does not enter it as a stranger. Instead, he enters as someone who has received care at various locations within this particular health system in the past. The moment he provides his identifying information, he becomes known to everyone he sees – from the person who takes care of his registration, to the financial counselor who verifies his insurance, to the radiologist performing his X-ray study. And by interacting with, and adding to the information that has previously been entered by all the different clinicians who have ever been a part of Mike Smith’s lifetime care team, his ED physician becomes that team’s newest member and the first to begin documenting this latest chapter in the story that is his ongoing health history.
But this organization’s connectivity does not stop inside the health system. Instead, the system has extended the continuity of the care it can help provide by using its integrated EMR to connect to clinicians who participate in the community physician Quality Choice partnership program.
An outgrowth of the ability of digital information tools to capture, record and report on the discrete information documented by clinicians during the care process, the community physician Quality Choice program is an organization composed of both physicians who are employed by the health system and regional physicians in private practice who either lease a customized version of the system’s EMR that is available as a secure online service, or who use a certified EMR that is interoperable with that system. To participate in the Quality Choice partnership, physician practices must agree to meet a number of clearly defined quality metrics and to provide evidence that they are meeting or exceeding these quality scores through a monthly report generated by a third-party from the information they document in the EMR.
The benefits of participating in the Quality Choice partnership for physicians in private practice are the right to publicly site their “member in good standing” status as a way of differentiating themselves in their local market based on the quality of their work and inclusion in selected payer contracts negotiated by the health system. The benefits of the Quality Choice partnership program to the health system are increased care continuity, including informed patient “hand-offs” or “transitions of care” based on need and specialty expertise, measureable quality consistency and increased patient satisfaction. And the benefits to the patient are choice, because of the variety and wide physical and specialty distribution of Quality Choice physicians throughout the region, and the peace of mind that comes from knowing that any Quality Choice clinician they choose is consistently and demonstrably delivering high quality care.
2.2.3 The Quality Choice clinician visit, and the surgical evaluation
The morning after his basketball mishap, Mike Smith visits a local orthopedic specialist who is a member of his health system’s community physician Quality Choice partnership. The first thing he notices is that, even though he has never visited this physician before, he is not asked to fill out any lengthy forms or questionnaires. Instead, the physician assistant simply asks him to verify certain demographic and incident-related information, and then the physician consultation begins.
Using the same integrated EMR system that the ED physician used the day before, the Quality Choice clinician reviews the details of the accident, studies Mike’s X-Ray images and results, adds her own observations to the electronic medical record following a brief physical examination and, as predicted, uses the EMR to order an MRI at the imaging center across the street, which uses an information system that is interoperable with the system used by this physician practice. Ninety minutes later, Mike is back in the exam room where he watches his clinician use his on-screen MRI to deliver the news that, as a result of his tumble, he has a medial meniscus tear in his right knee and, as often happens with this type of injury, a torn anterior cruciate ligament, or ACL. While a more conservative treatment approach would be physical therapy and medication, because Mike is a particularly active man, and is very anxious to get back in the game as quickly as he can, a surgical repair performed by a Sports Health orthopedic surgeon sounds like his best course of action. So the Quality Choice physician refers him to a specialist in the health system’s Orthopedics Department, and a member of the office staff uses an online scheduling tool to book his appointment for a surgical evaluation later that afternoon.
Deliberately arriving a bit early at the local family health center where his new Sports Health orthopedist practices, Mike takes a seat in the waiting room and fires up his tablet. Connecting to the health center’s WiFi, he opens his Gmail and finds a notice asking him to, “Please log into your personal health profile account because you have new information to review”. Because e-mail is not considered secure, any e-mail notification he receives about any of his healthcare-related activities contains only non-specific information with the invitation to log into his user ID- and password-protected account where he can view his personal health information in a secure, encrypted and HIPAA-compliant environment.
After logging in, Mike spends a few minutes using his personal health profile’s various features to complete a number of pre-surgical questionnaires that were automatically pushed to him when his appointment in the Orthopedics Department was verified in the scheduling system. In preparation for his surgery, he is also prompted to provide his own “personal preferences”, including any hearing or sight impairment he might have, any of his allergy or culture-related dietary restrictions or requirements, or any other special needs about which his caregivers should be aware as they construct his treatment plan. He then completes a series of financial clearance tasks, including insurance verification, co-payments and self-pay options, reviews the procedure-specific patient education information related to his surgery that was recommended for him based on the personalized details contained in his electronic medical record, and verifies that, of the available health system hospital locations where the type of surgery he needs is performed, he prefers the one that is closest to his home. Then a new notice pops up.
Clicking on it, he discovers that, because of the specifics of his injury, his age, level of physical activity and several other medical and demographic criteria, he is qualified to participate in a clinical research study designed to evaluate the tear healing of his ACL. The study is being jointly sponsored by his health system and a well-known scientific research organization, and after reading an overview of the purpose and goals of the study, he agrees to participate by e-signing a consent form and completing a very detailed condition survey that includes both discrete and free text patient-entered data fields.
Once he is called back to the examination room, Mike meets his surgeon, who reviews all of his pertinent previous treatment encounters and imaging studies, conducts an electronic medication reconciliation, documents that all necessary evaluation processes and materials are complete, and describes, step-by-step, everything that will happen during and after the surgery he is recommending to address Mike’s injury. Mike reads and then e-signs a “consent-to-treatment” form, and his surgery is scheduled for early the next morning.
2.2.4 Transformative features: care coordination, patient-entered-data, care guides
In the previous, Emergency Department portion of this story, we saw how integrated health information technology tools facilitated our patient’s ability to actively participate in the creation of his own connected, condition-specific care team by allowing him to select his doctors from a list of choices generated to meet his medical needs as well as the location(s) where his care would be delivered as determined first by his medical circumstances and then by proximity, appointment availability and other convenience factors.
By first ensuring that every member of the care team – from the Emergency Department, to the office of an affiliated privately practicing physician, to the health system-based Orthopedics Department family health center exam room – were always working from the same up-to-date electronic medical record data set, the health system’s EMR successfully accomplished the critical core functions of an effective language : it captured discrete data about Mike Smith’s treatment journey; it allowed that data, in accordance to a set of commonly understood rules and standards, to be organized and reorganized into new information; and it stored that information in a way that made it accessible, and useful – not only to his caregivers, but also to Mike Smith himself. By using the information recorded about him (diagnostics, treatment plan, ongoing status) and entered by him (demographics, subjective assessments, personal preferences) in the EMR as the measures upon which his options were based, the system substantially reduced the likelihood that Mike, or any of his clinicians, would make anything but a fully-informed choice.
Just as one effective way to help minimize the possibility of making a non-optimal choice is to first weigh a group of potential choices against the best available evidence, and to then make a decision by selecting from a remaining list of options that have each met an evidence-based standard, using a best-practice-informed, technology-enabled processes will now become a common feature in the rest of our story. Because, while it may not be immediately obvious to Mike Smith (caught up as he is in the moment and doing his best to remember everything he is being told regarding his experience and recovery), underlying all that happens from this point forward is the active application of the accumulated skill and experience of whole teams of clinicians representing multiple specialties and disciplines. In this particular regional health system, this process is called a “Care Guide” – and it is important.
Several years prior to Mike Smith’s basketball mishap, the leadership of the regional health system’s multidisciplinary group practice conducted a careful assessment of the way its clinicians and other caregivers aligned to care for a group of common or particularly complex conditions. What they found was that across the health system, multidisciplinary care teams composed of medical doctors, surgeons, nurses and other allied health professionals were increasingly utilizing the organization’s integrated information technology capabilities to collaborate and communicate. Leadership therefore empowered the organization’s innovative clinician staff to identify care team best-practices specific to selected conditions, disorders or procedures, and to define ways that the EMR could serve not only as a connectivity tool, but to deliver highly-focused clinician decision support options. The resulting initiative allowed some of the most accomplished and experienced clinicians in the world to come together to identify their group’s best judgment about the most effective path a specific type of patient’s care should follow and configure the integrated information connectivity systems to support the consistent delivery of that specialty-guided care, anywhere across the health system, regardless of how far the organization grew. The final result of these multidisciplinary clinical/technical efforts were what the clinicians called multidisciplinary, technology-enabled Care Guides. The work that went into their creation was illuminating.
The first step toward operationalizing a technology-enabled Care Guide is the creation of a care team-approved, condition-specific Care Set. This single document reflects all of the best practices identified by acknowledged experts in all the pertinent disciplines related to the care of a condition such as prostate cancer or a stroke, or the delivery of care related to a particular procedure such as total hip or knee replacement surgery.
At the start of the initiative, an initial proof-of-concept Care Set is finalized. Then that Care Set is subjected to a detailed review by a team of technology professionals who map the activities of the envisioned care flow against an information management schematic, plotting each of the required steps to a simple binary yes/no, if this/ then that structure. Following this demanding process, each step in the Care Set that involves a recommended course of action based on documented data points is programmed into the electronic medical record system. Working closely with an existing physician advisory group charged with evaluating ongoing clinician-suggested improvements and modifications to the health system’s EMR, the programming team constructs a technology-enabled Care Guide that presents its alerts and on-screen decision-support opportunities in real-time, and in ways chosen as effective and non-obtrusive by the clinicians themselves. No system-initiated recommendation can ever supersede a clinician’s judgment, but in some cases the workflow asks the physician to provide documentation of the specific clinical reasoning for not incorporating a Care Guide-identified treatment component (which is particularly useful in improving the Care Guide through real-world clinical application).
After an initial pilot period that gradually expanded through the health system proved the viability and reliability of the first technology-enabled Care Guide, this same development process became the health system’s standard after it was modified to include a standardized pre-review step designed to address issues and components that were proven to be common to virtually all clinical workflows.
So, with a multispecialty-developed, technology-enabled Care Guide working as part of the very infrastructure of the organization through which his surgery and subsequent recovery services would be delivered, Mike Smith enters an environment in which literally every component of the care he receives has been evaluated and measured according to the collective experience of dozens of highly-trained, highly-skilled clinicians while the facilities at which each episode of his care takes place, and the skills of the caregivers delivering those services at each step along the way, are being carefully coordinated to ensure that all available assets are utilized in the most efficient and effective manner possible.
2.2.5 Surgery, recovery and additional patient services
Following the surgical repair of his torn ACL, which took place at the hospital he selected because it is within a forty-five minute drive of his home, Mike Smith uses the scheduling function in his personal health profile to coordinate his post-surgical physical therapy encounters, which are offered in multiple family health center locations. During each physical therapy session, his progress notes are entered into the EMR by his therapists for review. Also, utilizing secure, remote monitoring technology such as a digital blood pressure/pulse rate monitoring device, Mike transfers data directly into his EMR so that much of his work can be overseen by his therapists without the need for him to actually visit a health system facility. And, all along the way, he receives secure ongoing updates and messages from various caregivers involved in his recovery through his personal health profile account.
Once he is fully recovered, Mike’s eye again turns to the outdoors. Though he missed most of the summer’s best weather, there is still plenty of time for him to enjoy his favorite activity, cross-country cycling, before fall’s turning leaves transition to snow, which moves his exercise activities back indoors to the stationary bike and the other equipment he has in his home gym. At his last physical therapy session, he expresses his intention to “get back on my bike”, and his therapist recommends that he consider enrolling in a supervised program offered by the health system’s Sports Health team. Called the “Cyclist Performance Training Plan”, the progressive workout regimen includes both supervised onsite and web-based components that will allow Mike to use his secure online personal health profile to record and track his performance progress (including data entered directly from a set of metabolic monitors that record his heart-rate and other dynamic indicators of his effort and exertion), see data downloaded by the caregivers who are monitoring his activities (including nutritional counseling and other performance enhancement tools and services) and allow him to schedule follow-up appointments with health system and regional Quality Choice private practice physicians if and when they are necessary.
The next day, monitors strapped into place, wireless bike computer calibrated to measure his distance and digital timer positioned on his handlebars, Mike sets off on what might feel like a solitary ride, but that actually includes an entire of team of caregivers who will accompany him over every mile, offering their expert guidance to help him achieve new levels of safe, individualized health and fitness. But as up-to-date as his virtual training team’s capabilities might be, the one thing that will remain beyond their scope is preventing another accident, whether on the basketball court or the bike trail. Though, if something like that should happen, they will be there to help, once again.
2.2.6 Transformative features: organizing a health system based on need, personalized patient services, eResearch
Leading from the understanding that the more often a clinician/care team performs a particular procedure, the better they are likely to become at doing it, various health-care theorists, including Michal E. Porter, Ph.D. and Elizabeth Teisberg, Ph.D. in their book, Redefining Health Care: Creating Value-Based Competition on Results,[10] have observed that this experience-based approach, if applied to the healthcare industry as a whole, could potentially change the way skills and resources are organized and distributed. Instead of a “full-service” model in which every hospital everywhere offers a full range of services, from delivering babies to heart or spine surgery, hospital-based centers of excellence could be organized in carefully chosen locations, giving caregiver specialists the opportunity to focus on just their area of expertise thereby improving their skills through experience and streamlining the health system’s resource outlay by reducing redundant services.
To accomplish this level of organizational efficiency requires access to detailed data, not only of the various quality metrics associated with a practitioner’s performance, but of the demographics and preferences of the patient population a health system serves. In the case of Mike Smith’s health system of choice, the integrated information technology-based EMR that caregivers and patients use to stay connected also connects the health system’s executive leadership to the kind of information that allows them to view their geographic region not as a collection of small, self-contained sub-markets radiating around each of their hospitals, but as a single, dynamic marketplace in which their resources can be organized to maximize clinical quality, minimize cost, and meet patient demand.
Several years before Mike Smith’s experience, the health system leadership transformed the composition and distribution of the organization’s resources based on real-world information. The work began with an analysis of data accumulated over several years through which it immediately became clear that the vast majority of patients are perfectly amenable to traveling a reasonable distance to the location where specialized surgery or other therapeutic procedures can be performed, but for follow-up appointments, rehabilitation visits and other post-surgical activities, they much prefer to stay closer to home. This data set was aligned with quality metrics reports that illustrated how clinicians who are allowed to focus all of their attention on their particular clinical specialty achieved demonstrably higher quality outcomes than those who are expected to spread their attention throughout a more general practice environment. In an effort to improve population outcomes and, ultimately, to attempt to lower some of the costs related to delivering care, the health system’s leadership decided to leverage caregiver coordination capabilities that were made possible by the system’s integrated EMR connectivity tools to reorganize their human and physical assets.
They began by first redefining the regional marketplace into three zones (east, central and west) and creating an inventory of all health system assets and corresponding clinical activities that took place in each of these zones over a quantified period of time. Lessons learned during this analysis showed that there were a large number of duplicative surgical and medical programs operating through multiple, often closely proximal facilities, the locations of which were the result not of any strategic application of resources, but of the organic growth of the organization over decades. Next, an integrated clinical, financial and system operations team conducted a base case analysis of a large number of randomly selected patients, creating a dashboard report that detailed the fixed and variable labor and supply costs associated with a cataloged health system “book of business” as well as all direct and indirect expenses. Almost immediately several factors became apparent. The first was that, across the various sites, there were few, if any standardized approaches to treatment, documentation or, significantly, resource purchasing or allocation. Second, the distribution of medical and surgical specialists and their associated allied support personnel was geographically sub-optimal, resulting in overlap and redundancy that created what was, in essence, an environment of internal competition between various health system-owned sites. And third, that as a direct outgrowth of this non-optimized distribution of human skills, physical assets and substantial savings through bulk purchasing and contracting opportunities going unrealized due to uncoordinated, site-specific management, the health system had a total cost per encounter for similar services that could vary by an extraordinarily wide degree.
To address these unacceptable variations, the health system executive leadership worked with department chairs, hospital presidents and administrative and other allied support personnel across the organization to implement a strategic consolidation of facilities and services through which they established several surgical centers of excellence supported by coordinated, zone-aligned outpatient, rehabilitation, extended care and other recovery resources, with only the most complex surgical interventions located on the central, downtown campus. This new distribution meant that the maximum distance a patient would need to drive for routine elective specialty care of any kind would be 30 minutes, 60 minutes for complex interventions, with consolidated rehabilitation and outpatient facilities keeping expected patient drive time down to twenty minutes or less. Across this re-imagined system, specialty-designed Care Guides were applied to the majority of the common and / or complex procedures performed, increasing the efficiency of the continuum of care in optimized clinical spaces that are better utilized by more specialized staff.
Initially, this repurposing of facilities and reorganization of staff was met by expressions of disappointment by a community that believed, understandably though incorrectly, that something important was being “taken away” from their local hospitals. But a carefully crafted public relations effort through the health system’s Media Relations and Marketing departments outlined the benefits of the model to the area population, including directly addressing some of the “harder” questions that were raised by citizens and local newscasters. Within three months the public’s concerns transitioned to an understanding of the ways in which the health system’s changes improved the level and quality of the services delivered, and the organization saw measurable reductions in both cost per case and cost per unit of service accompanied by increases in outcomes metrics and patient satisfaction.
Returning to Mike Smith’s personal experience as our example, we can see how these changes aligned to offer him greater provider choice, improved care quality and a patient experience that kept him connected to his caregivers during every step of his treatment and recovery. This connected style of patient experience also provided him with a number of unique patient-centered services, such as the cycling performance program conducted by the Sports Health portion of the Orthopedics Department which had both regional and online connectivity opportunities that allow patients everywhere to benefit from its expertise.
Which leaves one very important component of Mike Smith’s care that we have yet to address: the research study in which he agreed to take part.
Our earlier description of a paper medical chart as a “dark prison” was deliberately selected because, for all practical purposes, information recorded on paper and then filed away in a chart storage facility all but completely disappears from view. As evidenced by the tremendous amount of time, effort and financial expense associated with clinical trials and practically every other type of medical research conducted over the past hundred years or so, paper charts are an unwieldy medium that only slowly gives up its secrets. But in a practice environment in which patient information is entered as discrete, searchable data points, the power of computer systems to do what they do best – rapidly collate, organize and reorganize selected information –frees human investigators to do what they do best: analyze information and creatively arrive at conclusions that can then inform future clinical behavior.
Already, as part of our fictional health system, discrete, de-identified patient data is being parsed and dissected by interested clinicians and endlessly curious physician scientists who are formulating new queries and running increasingly complex reports against a database that contains the continually-updated treatment specifics of over five million individuals. And because this health system is a recognized national and international tertiary care resource for several medical and surgical specialties, the demographic depth and richness of this patient population closely reflects the general population in a range of statistically significant parameters. So, in addition to serving as a guiding light that illuminates the organization’s executive and physician leadership’s efforts to design a more effectively competitive health system structure, the data entered about and by the patients served in every facility of this growing enterprise is also revealing more, with each new query and every passing day, about the clinical efficacy of today’s medical and surgical treatments as the data-driven, outcomes-based prologue that will lead to the innovations and breakthroughs that will result from tomorrow’s new knowledge.
2.3 Conclusions
We began our discussion by drawing a parallel between written language as perhaps the most broadly significant human technology ever developed and the emergence of a contemporary medical practice environment that can leverage the most significant technologic development of the past several centuries – namely machine-enabled computational power made widely accessible to individuals and organizations – to create a new way of understanding the health status and healthcare needs of our fellow human beings. This new technology-enabled language, still in its relative infancy, promises to deliver a transformation no less profound than what language itself initiated across human culture; if, that is, it can be used in ways that will maximize its value.
What is true at the moment is that, for the first time in the history of modern medicine, people of differing backgrounds who represent a range of medical, cultural and societal disciplines and perspectives are beginning to “see” into the murky ocean of data that, up until so very recently, had been all but completely obscured behind the covers of countless paper charts. As they gaze into data’s nether reaches, they are discerning the first faint outlines of the underlying structures of some of the most burdensome diseases that have afflicted us and impeded our ability to thrive for a very, very long time. Given further time and study, we can reasonably expect creative and innovative people to see beyond these dim first glimpses and collaboratively discover ways to construct new, working interventions based on real, verifiable evidence that might, one day, relieve our suffering and, potentially, even extend the joy and satisfaction of our useful, healthy lives.
And, as we saw over the course of our brief story, each progressive step in this promising process can be fabricated from three simple, language-analogous building blocks:
- Discrete standards-based information capture: the “words” that form the vocabulary used by care teams to collaborate with one another, and with the patients they treat.
- Security-protected, privacy-controlled information access: the grammar that allows data to be arranged and rearranged into meaningful statements and new understanding.
- Widespread adoption and use of interoperable information technology tools: the real-world, meaningful communication between people that is the final goal and driving point of the entire technology-enabled process.
Going forward, medical professionals, payers, policy makers and patients everywhere will have the opportunity to help guide the creation of a renaissance in the ways in which people can join together to confront the diseases and physical and cognitive impediments to health and vitality that have been so unavoidably a part of life since life itself began.[11] But as we saw in our fictional patient’s story, for this information-driven process to truly deliver on its promise, it must be used as a bridge that will link patients and providers, researchers and the manufacturers of medications and medical devices, insurers, employers and their employees, government and other regulators, and the constituents of what may historically have been perceived as competing interests into a functional network of data-driven, success-oriented activity and achievement. Because, as we have implicitly observed, there is work enough for all, and abundant opportunity to succeed and to serve. The model outlined in our fictional healthcare delivery system can be imagined as expanding beyond a single market or region to become a national healthcare resource with centers of excellence specific to different conditions linked by interoperable information systems not only to one another, but to the regional and local provider organizations that will deliver the post-intervention rehabilitation and ongoing care patients will need once they return home from travelling to the right specialist for their condition.[12] Widely available outcomes reporting based on clearly defined, comparable information will not only help guide patient choices and physician referral relationships, but will also contribute to a broader understanding of which interventions and therapies are most effective [13] and therefore most likely reduce a full cycle of care costs by reducing further complications or recurrences. This same data made available to medical researchers bolstered by increasingly sophisticated information management systems could help to significantly reduce the time it will take for a new medication to move from the researcher’s bench to the clinician’s toolset[14] and help population health monitors track emerging illnesses such as flu or other conditions spread by human movement and contact.[15]
And finally, this new technology-enabled language could one day bring together not only the clinicians and allied health professionals dedicated to caring for a local, regional or national community, but those individuals and groups around the world dedicated to this kind of work wherever they call home.[16] Because, on this small planet, where the mobility of people, food products, livestock and goods of every kind has all but completely erased even the most tangential barrier between cultures or groups, the ultimate health of any one of us may well rely, to an increasing personal degree, on the health of us all.
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