By Robert Pearl, MD, guest blogger
The technology boom of the 1990s promised to give physicians access to comprehensive patient information and replace outdated paper records. But it wasn’t until 2009, when Congress ratified the HITECH Act to “promote the adoption and meaningful use of health information technology” and paired it with financial incentives that EHRs became widely adopted.
This technology was supposed to improve U.S. healthcare and improve the lives of physicians. Instead, billing and documentation requirements that once took physicians only a few minutes consumed as much time as direct patient care. An observational study in the Annals of Family Medicine found that family medicine doctors currently spend over half their workdays staring into the abyss of their EHRs.
For the most part, that additional time hasn’t improved care quality. When Johns Hopkins published a follow-up study to the 1999 “To Err is Human” study from the Institute of Medicine, it found that the number of annual medical errors had actually increased. What was the primary cause of those errors? The lack of communication and poor care coordination.
If we’re going to improve health, many Americans think we have to sacrifice one of the following: service, cost or quality. I disagree. By improving operational systems, introducing available information technology and avoiding complications from chronic disease, we can improve service and quality while lowering costs. To do so, we need to make healthcare delivery far more coordinated and connected than it is today. Otherwise, the alternative in a time of recession is going to be to rationed care, which would be a major loss for the U.S. populace.
Addressing the limitations of today’s EHRs
Appropriately used, technology can help us improve care coordination and delivery without adding to the physician’s burden. That hasn’t been the track record of EHRs to date. Instead, they’re a major contributor to today’s high rates of physician burnout. A recent Mayo Clinic survey found that physicians gave EHR usability a grade of “F.”
It doesn’t have to be that way. When used optimally, data has the potential to reduce burnout and increase the time physicians spend with patients. To accomplish that, Congress will need to force EHR vendors to open their application processing interfaces (APIs) to third-party developers. They can then create applications that allow clinicians to extract data, use hand-held tablets and access comprehensive patient information at every point of contact. Given that what exists in the EHR is an individual’s personal health record, it belongs to the patient and should be available wherever he or she might travel or choose to receive medical care.
The value of virtual care
in addition to the EHR, a second technology that can improve the coordination and provision of care is the use of video. I believe that video, which is relatively inexpensive and overcomes the problems of distance and time, is our nation’s most underused technology. I foresee that about 30 percent of what we do today in physicians’ offices will be delivered via telehealth in the future.
We can use this technology to prevent people from having to miss school or work to receive medical care. And it can bring expertise to patients regardless of where a particular medical expert is located rather than limiting them to consulting a provider who’s within driving distance. Video technology can also leverage expertise to improve care in the hospital; for example, enabling a neurologist specializing in stroke care to provide immediate expertise for patients in multiple emergency departments spread out over a large geography. Using video, physicians in the Permanente Medical Group were able to lower the time needed for definitive treatment from about an hour to 27 minutes.
Video technology can also improve care coordination after patients are discharged from the hospital. Physicians and care teams can set up a video visit a day or two following discharge to ensure patients are taking their medications as prescribed, appropriately managing their medical condition, changing surgical dressings and so on. Caregivers can participate as well to ensure that everyone understands what needs to happen. This opportunity to improve communication and coordination outside the hospital is crucial if we’re going to avoid the kinds of medical errors that plague our country today and reduce the frequency of hospital readmissions.
But what should be a continuous process of sharing data and expertise between inpatient and outpatient or post-acute care facilities is often missing.
This is where these technologies can fit together, enabling the comprehensive electronic health record to be available to physician experts even if they’re a thousand miles away. In this way, they will have all the necessary information, including laboratory, radiology, operative and other data, to make optimal clinical decisions without delay.
Data analytics represents the future
The future of technology, from my perspective, is data analytics. Ideally, that will combine information availability, algorithmic tools and artificial intelligence. The amount of health data is increasing at an unprecedented pace, with more being created every two years than has existed in the entire history of medical care. And that trend is only going to accelerate. A typical hospital has several hundred inpatients, all of whom have a series of laboratory reports, radiology results, physician and nursing notes, as well as continuous monitoring information. While the human brain is incapable of understanding all of that data, for a modern computer, it’s pretty trivial.
Computer algorithms can help physicians predict which inpatients in a med/surg unit are likely to become sicker overnight and deteriorate to the point where they need ICU care. That’s important because when they deteriorate, the mortality rate goes up by a factor of four and costs increase significantly. When you can use data analytics to identify the 1 percent of patients who are likely to fall into this category, you can proactively intervene to raise quality, lower costs and make care more convenient. Sepsis is an example where data analytics can identify individuals with a seemingly routine infection who are at high risk, treat them more rapidly and cut mortality rates from 16 percent to 8 percent. The combination of data and algorithmic solutions enables doctors to diagnose faster, intervene quickly and effectively coordinate the efforts of the entire clinical team. As our nation moves from “pay for volume” to “rewarding value”, businesses and insurers are going to want to know which providers deliver the highest quality care in the most convenient way at the most affordable price. Organizations that have and use the best data analytics and most effective technology are going to be the winners. Organizations who wait will be left behind, watching from the sidelines as competitors gain the contracts and establish trusted relationships with employers.
During my time as the CEO of the Permanente Medical Group, we wanted to make sure that the quality and service we provided to over 5 million Kaiser Permanente members were market-leading. To achieve that, we relied on a series of comparative performance reports. For example, our physicians received monthly reports that measured their clinical outcomes in caring for patients with a variety of diseases, including effective blood sugar control in individuals with diabetes and normalization of blood pressure in people with hypertension. We used that performance data to identify superior approaches to medical care and drive better outcomes. As an example, while among patients with high blood pressure the national average for successful control was only about 55 percent, our average was 92 percent. That reduced the risk of stroke in our patients by some 40 percent and, combined with other preventive measures, diminished their risk of a heart attack by about 50 percent.
I’m often asked how to overcome the resistance many doctors have towards a data-driven approach. My answer is to apply what Carol Deweck, a colleague at the Stanford Graduate School of Medicine, has called a “growth mindset.” We all can get better by working together. At the Permanente Group, I introduced the idea of group excellence – measuring our ultimate success by how the entire medical group did, rather than each individual physician. That approach, combined with our advanced information technology systems, enabled us to move from ranking slightly above average to being consistently rated by the National Committee for Quality Assurance in the top five programs in the United States. That success was only possible because we had that data and used it to collaborate and coordinate care.
These same approaches can be used by other groups to help them stand out as providing higher quality at lower costs when health plans are selecting their network providers. The data help individual clinicians to perform better and allow organizations to demonstrate to employers and insurers the superiority of the medical outcomes they achieve.
My bias is that when organizations are integrated, so that physicians work together as one, are paid on a capitated basis, have the most advanced technology and are led effectively, they consistently outperform the competition. If we are going to flatten the healthcare inflation curve and make the United States the global leader in clinical outcomes that it should be, these four pillars (integration, capitation, technology and leadership) can serve as a solid foundation upon which to build.
Every other industry has used information technology, data analytics, and artificial intelligence to advance performance. Medicine remains trapped in the last century. Change is necessary to address the growing healthcare crisis our nation faces. The time to embrace these powerful technologies is now.
Robert Pearl, MD, is passionate about transforming the American healthcare system and helping people understand the consequences of their medical decisions. A Board Certified plastic and reconstructive surgeon, a clinical professor of surgery at Stanford University, and on the faculty of the Stanford Graduate School of Business, he previously served as CEO of The Permanente Medical Group and as president of the Mid-Atlantic Permanente Medical Group. Dr. Pearl is the author of numerous blogs and articles, and a book, “Mistreated: Why We Think We’re Getting Good Healthcare – And Why We’re Usually Wrong.” His website is RobertPearlMD.com.