ZachEvans

Believer. Husband. Dad. Coach. Healthcare Thought-Leader. All-Around Good Guy.

Healthcare

Rethinking Support

by

When I took on TriStar Centennial Medical Center as their IT Director, I inherited a team of nearly 30 seasoned, dedicated team members that were good at their jobs. The knew the facilities (650+ beds spread out over multiple campuses) inside and out, had long-standing relationships with both staff and leadership, and were–generally speaking–well thought of by their peers. It was, in my opinion, a good team to take on as a leader.

Talking with the team over my first few months, however, I discovered underlying feelings and perceptions that ran contrary to the results we were delivering. While we had reasonably high employee engagement scores, there was a sense of discontent and a feeling of being beat down by the work. When I took a step back and reflected on all of conversations with the team, I had a few questions that I needed to answer:

  1. How can such a well-established team, with positive working relationships, feel this way?
  2. How are these feelings impacting the service we are being asked to provide?
  3. How are these feelings limiting our relationships with the rest of the hospital?

As I dug in to the answers of the questions, I came to the conclusion that the team loved the people they worked with but they did not love the work and I thought I knew why.

Imagine a job where, generally speaking, the only time your phone rings or you get an email is because something is broken and needs to be fixed. That even with the implementation of a new project, most of your time is spent answering the question: “Is it done yet?” The very basis of your work is rooted in negativity that will–over time–impact your view of the work that you do. No one may be trying to run you down, but run down you become.

After quantifying these feelings, I tested my theory with the team and they confirmed that, yes, it is difficult to constantly feel this way. The celebrations of success were few and far between (something that we fixed) and there were not many ways to measure success available (also something that we fixed). In my quest to further solve this problem, however, I began to rethink the entire concept of what it means to provide support (in this case, specifically, IT support).

What happened over the next several months was a transformation of the work that we did in the hospital, measured by our top marks in employee engagement and customer satisfaction (out of the 14 facilities in our division). How did we accomplish this? By putting the patient in the middle of the support we were providing–even when no one on my team was involved in direct patient care.

Gone were the days where we were fixing a broken printer. Now we were enabling a nurse to print out discharge instructions on a timely basis to help a patient get home quicker.

No longer did we install new equipment simply because a clinician asked for it. Now we installed new equipment because it provided additional tools to the clinician to provide higher quality care with better outcomes.

Furthermore, I wanted my team to ask themselves two questions each day (since refined): 1) “What can I do today to impact the care given to our patients?” (beginning of each day) and 2) “What have I done today to impact the care given to our patients?” (end of each day).

By putting the support our team did in terms of how it helps the patients we are called to serve, we now had a foundation for greater satisfaction in our work and happiness in our jobs. All by rethinking support and what it means. It is a process I am just now beginning to roll-out to another team I have the pleasure of leading. This time, however, I am even taking it a step further by implementing the concepts in coordination with the clinicians we support. I suspect that I will see similar (if not even better) results.

Urgent, Not Emergent

by

A statement in a recent article from The Motley Fool attributes the rapid rise of urgent care clinics to failures by hospitals.

Long waits in emergency rooms for breaks, sprains, and the flu coupled with triple digit out-of-pocket invoices are making hospitals the care-of-last-resort.

The issue I take with this statement is that it leaves out the fact that the emergency room may not be the best place to treat breaks, sprains, and the flu in the first place. There is often a wide gap between a healthcare need that is urgent and one that is emergent.

Over the past several decades–driven in large part but the rise in the uninsured–emergency rooms became the primary treatment provider for all kinds of healthcare needs that were not, in fact, an emergency. Emergency rooms, by law, are required to treat almost any patient that presents at their door regardless of their ability to pay (this is a good thing) but have limited say in what patients actually show up requesting care.

Is the patient with the sprained wrist or suffering from flu-like symptoms experiencing a healthcare emergency? Most likely not, but many of them came to the emergency room anyway–often driving up the wait times mentioned in the article.

Urgent care centers, walk-in clinics, work-site clinics and the like are excellent avenues for patients with urgent–but not emergent–healthcare needs. Their rise in popularity (and the financial success that is following) should not be viewed as a failure of hospitals, but rather as a success of patients selecting the right provider for their current healthcare needs.

Motivating the Right Party

by

Patient engagement is a popular buzz word in healthcare circles right now. Motivation to increase the engagement of a healthcare provider’s patients vary  but most–if not all–center on the idea that an engaged patient will be a healthier patient. Employers want engaged patients because employers want to speed-up the role out of consumer driven health plans. Insurance companies want engaged patients because they want to keep down medical expenses (so do employers and the patients themselves). Doctors and hospitals want engaged patients because engaged patients can be marketed to directly regarding one doctor’s or hospital’s strengths compared to another.

CMS has even expanded its focus on the engaged patient with the requirements to meet Meaningful Use Stage 2. As part of MU/S2, patients are required to be given expanded electronic access to their medical records, access I strongly support as this data is owned by the patient, not by the doctor or hospital that provided the care.

The Core Measure relating to Patient Electronic Access has as its objective to “provide patients the ability to view online, download, and transmit information about a hospital admission” and is broken down in to two parts:

  1. More than 50 percent of all unique patients discharged from the inpatient or emergency departments during the EHR reporting period have their information available online withing 36 hours of discharge.
  2. More than 5 percent of all patients (or their authorized representatives) who are discharged from the inpatient or emergency department during the EHR reporting period view, download or transmit to a third party their information.

I appreciate and agree with the first requirement. Given the technology of today and the general acceptance of consumer portals, hospitals should be required to give patients access to their healthcare data and it should be available in a timely fashion. The first incarnation of HIPAA provided a common framework for patients to request copies of their data, but the process was sorely outdated and expensive to both parties involved.

It is the second requirement that I take issue with. I am proud to work in healthcare and for a hospital company. I firmly believe that we have a near-sacred responsibility to provide the highest quality of care to the greatest number of patients. We see patients at their weakest and most vulnerable moments. We have a responsibility to give them the necessary care to help them get better. We do not, however, have a responsibility to ensure that they are engaged in their care.

Yes, we have a responsibility to educate them about all of the care options and resources available to them. Yes, we have a responsibility to remove as many barriers as possible when it comes to accessing those care options and resources (see the first part of the requirement above). I fail to see, however, why a hospital should be held accountable for a patient that refuses to actively engaged in their own healthcare.

Where is the personal accountability for ones on health? Why are we not motivating the right party to become more engaged in their own health?

Contrasting Practices

by

I recently completed a short training course produced by a colleague of mine, Dr. Mark Radlauer, who is both an emergency room physician in Colorado as well as an early-stage tech investor. The topic of the training course was improving IT-Provider communication. Dr. Radlauer is a voice I listen to because he understands the clinician’s point of view and workflow and he is a firm believer in leveraging technology to deliver the best patient care and experience possible.

Dr. Radlauer pointed out, correctly, that one of the leading causes of communication challenges between IT professionals and providers is that contrasting practices exist in terms of how each individual approaches their work.

Contrasting Practices

(The one point where I slightly disagree with Dr. Radlauer is in his assertion that IT is organization-driven rather than data-driven but my experience shows that this is sometimes the case. IT–and most all businesses / departments / teams–should be more data-driven than they currently are.)

I believe that seeing a construct such as this helps both IT professionals and clinicians understand the points of view of the other party and, therefore, improve overall communication between the two groups. When communicating across disciplines, it is always helpful to understand how the receiver of your messages (regardless of how they are sent) works and thinks. This understanding will allow you to tailor your message to be as effective as possible.

 

A Well Designed EHR?

by

A dirty little secret about a lot of EHR implementations is that there are often negative impacts on productivity post implementation. This is about much more than leading your team through the valley of despair associated with almost any change. This is about the fact that an EHR implementation fundamentally changes the way nurses and physicians actual practice. A recent article by Paul Roemer over at healthsystemCIO.com points out a very important reason for this:

You EHR was not designed to work efficiently in an non-linear exam. Chances are good that your EHR was never really designed at all. Were designers, professionals with advanced degrees in human factors — cognitive psychology, heuristics, taxonomy, and anthropology — asked to determine how the EHR would need to work? Did they watch users work prior to writing code? Did the EHR firm iteratively build prototypes and then measure how users used it in a research lab that tracked hand and eye movements? If not, that is why I think it is fair to characterize EHRs as having been built, not designed.

Most software, including EHRs, were built using linear logic. Step 1, Step 2, Step 3, etc. When you’re dealing with patients who often are scared, confused, in pain or all three (or more besides) linear logic breaks down. Healthcare providers need the ability–provided by their EHR–to jump around with the patient to make sure that everything gets documented as completely as possible in order to take advantage of all of the benefits that EHR offer. It’s also another good argument for the need for patient-centered EHRs.

You Don’t Always Get What You Pay For: Part 2

by

Several months ago I wrote a post about how we don’t always get what pay for in regards to healthcare. To follow-up on that theme, today I came across an article detailing how private insurers are better than government insurers in controlling expenditure growth.

Per Capita Spending Growth

Supporters of a single-payer system have long touted the fact that Medicare and Medicaid process claims cheaper than commercial payers but as pointed out by Avik Roy for Frobes.com, even these figures are misleading.

Medicare Versus Private Insurer Spending

So, if private, commercial payers are better at controlling expenditure growth AND are more efficiently administratively, why are we still talking about a single-payer system?

(We still need to deal with profit motivation / maximization and neither of the two studies compare expenditures and administrative costs to the growth in premiums but those are topics for another post.)

Patient-Centered Spending

by

Want more proof that lifestyle choices are driving the majority of healthcare expense in the United States? A recent study highlighted by the Healthcare Economist blog looked at data from the Medical Expenditure Panel Survey and broke it down in to “patient-centered” categories. The findings: About 47 percent of all healthcare expenditures are related to chronic conditions.

Granted, some chronic conditions are a function of genetics or just plain bad luck but many are not. Many are a direct result of poor personal choices that result in obesity (from overeating, lack of exercise, etc.), or respiratory issues (from smoking), or diabetes (often from the same choices result in obesity), or [insert chronic condition here] (from [insert poor personal choice here]).

Now, I’m not a health nut. I enjoy red meat and could probably stand to lose a few pounds. I do try to take care of myself, however, and accept the fact that I have a personal responsibility to make as many healthy choices as I possibly can. This not only makes me feel better, but provides a good example for my boys and [should] keep my medical expenses down as I go through life.

For some reason, though, many people choose not to accept personal responsibility for their health and their choices directly affect all of our health insurance premiums, which they’re often the first to complain about when the premiums are going up. What we all need to understand is that responsibility and better outcomes tend to go hand-in-hand.

Patient-Centered EHRs

by

In recent years (especially with the advent of the Patient Protection and Affordable Care Act) and new (actually really old) term came back to the forefront of our healthcare system: Patient-Centered Medical Home.

The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.

The reason that this is a new idea is that as recently as fifty years ago our healthcare was (primarily) managed by family physicians that knew us personally and took care of most of our needs. (We also paid for most of our care out of pocket, but that’s another post.) With increased specialization and insurance reimbursement, however, our healthcare system fractured in to the model we have today: We typically run to a disconnected specialist first before talking to our primary care physician.

HMOs tried (in vain) to reintroduce this hub-and-spoke model but consumers never got comfortable with the idea that someone in a cubicle hundreds (or thousands) of miles away got to decide if they needed a procedure or not. The patient-centered medical home tries to improve this model by placing a primary care physician at the center of the wheel to work with you on the best course of your care.

Supporting this model (or at least it’s supposed to be supporting the model) is a significant amount of technology that enables coordination of care across access points and stakeholders. The problem with much of this technology (especially EHRs) is that they’re not patient-focused at their cores. Too many EHRs (and the practice management systems that wrap them) are built with the payers and providers at their middle instead of the customers they both serve: Patients.

Usability is terrible. Interoperability is virtually non-existent (although it is getting better as the first HITECH incentive payments have started flowing). Providers are in revolt (see the usability comment above). And the patient is locked out of having visibility in to almost any of it.

I love the idea of the patient-centered medical home. I think it’s where healthcare really needs to go. Unless we put the patient at the middle of all of the enablers of the medical home, however, I do not believe we’ll be able to capture all of the possible benefits.