Care Delivery is an EHR and Health-Tech Afterthought

07/12/2016 03:15 pm ET

We have almost extinguished the plasticity and critical thinking capability of our great healthcare minds, forcing them to rigid formats of patient intake and discharge management. This was done with the good intentioned purpose of advancing care and expanding care access to the masses. Led by corporate lobbying and regulator folly, the clumsy product and unfortunate side effect, as we have read from numerous articles on productivity and safety, is we have strained the system, reduced patient touch points and confused the purpose of care. We are also impacting the future training of doctors to be EHR (electronic health record) transcriptionists, which does not bode at all well for the patient. An interesting experiment occurred in a clinic in NYC, where the EHR was turned off and the residents and medical students were asked to take a history from the patient. A significant awkward pause occurred after the perfunctory first question of, “What brought you here?” The trainees did not know what to do next without the prompts from the EHR. We have taken a billings tool in clinical clothing and superimposed a workflow with obscure guidelines that has crushed the sleuth mentality of the physician. Experienced physicians manage the cognitive dissonance but with severe frustration that impacts their work-life balance as they take the EHR administrative work home. We all admit that there are probably more inaccuracies in the patient’s record because of the EHR and that it has distracted us from doing our job. The interfaces of these health tech systems despite the iterative advances continue to be a significant hindrance to care delivery, and the quick templates may speed us up a touch, but does not improve the quality of care. The notion of completion, closed, or discharged on an EHR has a negative neurocognitive effect that prevents the doctor further investigating an issue with the patient. We all wonder now if that patient is being best served by our system of care delivery since the advent of the EHR. Rather than improve the quality of care the EHR has successfully controlled the quality of the care delivered to the patient and brought it down a notch. Current health tech creates enormous pressure on the care workflow and the people involved, causing it to prevent process improvement because each individual is simply trying to stay afloat and get the task list checked off, without any real clear and measurable link to the outcome.

Oh, then we added incentive payments! With misalignment to patient centricity and making it EHR task centric, it is like taking a track athlete and putting them in a sack race. If the performance indicators are not patient-centric and the responsibility not shared across a team you have caged the diagnostic capability of the team. It is hard for them to be appropriately responsive to the patient when they are assessed on utility of a bad technology. This is definitely something MBAs and administrators, and the larger culprit, the regulators clearly have not understood. The bonus payment for physicians is to have unfettered access to their patient and their colleagues in the patient’s care team to get the patient the best possible care, where and when it is appropriate. Having more happy patients and being enabled to deliver that quality of care they are trained to deliver, to more patients is a care provider’s nirvana.

So, how do we get out of this rut? To get us back on track we need new leadership and with a renewed sense of hope, I have seen the emergence of a new breed of physician and nursing leadership that is motivating their pop health initiative teams to engage the patient and provide different routes to care delivery, not to simply manage cost of delivery issues, but to better manage the patient and objectively take the data from patient self-reports and modify their clinical protocols. The art of medicine is to sense the patient’s need from clinical and interview data, supplement it with the right physiologic tests and come to a management plan bespoke to the patient’s circumstance. Embellishing the interview across new tech mediums, with highly contextual information about the patient is the next wave of care. 

I have heard many times that hospitals were built for the physician and not the patient. The clinics and care centers are network hubs and are built for the patient to spend time with their care provider in high tech settings to standardize and optimize the interaction to enable standardization and optimization of the outcome. We clutter these clinics with irrelevant activities that can be now done virtually and in combination with remote cross functional teams. The right technology and the right level of engagement by the patient can create the efficient spokes to the nodal hub infrastructure. To make this even more effective triage optimization on each call or enquiry from a patient will allow specific and targeted hub and spoke access to improve efficiency and flow for all concerned.

Let’s talk less about value based care and more about care based value. We have to provide the patient with the value they seek which requires transparency and convenience. The next generation of tools are enhancing the conversations with patients, care teams and providing vital decision assist capabilities as a functional tool to the physician and clinical care team. We must socialize the care teams and move to motivational recommendations. Care providers are desperately trying to move away from the structured checklist approach to a network data approach and do not want to be incented on the completion of tasks but the integration of tasks with teams. We need to move back to outcome of care and the efficient documentation of care to which the tech company must be held accountable. I would like to see implementation and utility scores be a measure of the tech company’s relevance to the outcome of the patient. Visionary medical school and patient population leadership is going to change this before it negatively effects the patient and worse, the job satisfaction of our extremely valuable care delivery professionals.

We must simplify the care delivery tech interface as a matter of urgency. Simplify it for the patient to access and understand their care and simplify it for the doctor and nurse to access pertinent care information and management order tools. The UX of care is not just a UI challenge, it is a re-engineering of the network of interfaces that are utilized to access and deliver care.

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