A Wish List for Health IT

As we approach the end of the year, it’s a good time for reflection. Is there a “Santa’s wish-list” for Health IT? Can we formulate a good vision of what will help health care move forward?

Health IT, after all, is a set of tools – it does not replace the practice of medicine, nor does it change the fundamental dynamics of how the health care delivery ecosystem functions. But it can facilitate the kind of things that need to change, in order that (as individuals, and as a society) we can deliver a service that is better quality, more personalized, improved-outcome and lower cost. That may seem like a conundrum, if one adheres to the traditional belief that “more care is better care” – but an impressive body of evidence illustrates that “doing things right” and “doing the right things” in health care results in better outcomes and lower cost.

In a stirring speech by the outgoing CMS chief Don Berwick, he reminded us all that “staying focused on the patient” is the underlying theme that must drive health care. This resonates closely with the value statement of “focus on the customer, and everything else will follow” – in health care, the patient is our ultimate “customer.”

So, in order to construct our “wish-list,” we might want to look at things from the perspective of the individual practitioner, and then from the perspective of the health care delivery system as a society. What do we need for Health IT to do for us, from each of these points of view?

The view from the individual clinician
As health care practitioners, we want to fit ourselves to be of maximum service to our patients. How do we do that? How do we provide care that our patients will experience as “excellent”? In this modern age of technology, how can we deliver care that is both high-tech and also high-touch?

Well-designed technology can (should) facilitate the human-to-human interaction that is at the core of health care. It should not stand in the way, distracting focus away from that human interaction – to the extent to which technology systems require focus on the tools, rather than the patient, then that is a design flaw than calls on Health IT developers to fix.

A rule of thumb I heard many years ago summarizes how patients perceive satisfaction with their health care experience as (1) did I get in quickly, (2) did I get out quickly, (3) was I treated well, and (4) did I get better? Can Health IT tools facilitate these things?

So let’s create a “Santa’s wish-list” from these perspectives – at least where it comes to delivering care in the traditional setting of in-office visits. Delivering care in the “true patient-centered home” – the actual patient’s home – though different, can still draw from these same four points.

1. Getting in quickly. We need self-service tools available to the patient which allow for scheduling, and quick check-in. Making appointment through a patient portal, or changing appointments when needed, need to be done in a way that works both for the medical office as well as for the patient. Past Medical History, and all the traditional paper forms that we, as patients, need to fill out with each new doctor’s office, need to be shared, automated, and completed only once. On-line if possible, or with a coach/facilitator if necessary.

2. Getting out quickly. The office workflow needs to be smooth and efficient. The patient’s record needs to be at-hand when needed, and any outside information (like hospital records, labs, etc.) need to be available at the time the visit is occurring. Processes that may or may not occur during a clinical encounter – such as prescription refills, and handling messages from patients (by phone or on-line) – all need to be done efficiently, correctly, and once. The clinical documentation of the encounter needs to be done so quickly that there is little “system time” needed between each patient encounter – this is the biggest factor that slows down the pace of office flow.

3. Being treated well. In part, when clinicians are freed from the burden of “the system getting in the way of the individual,” it is possible to pay attention to good customer service. This involves everyone, not just the doctor. It means training the staff in good communication skills. It also means having the tools for carrying out the tasks at-hand (like referrals, post-visit orders, scheduling follow up, managing billing) being readily available – most “bad” customer service stems from frustration with inefficiencies in the system, which can lead to the adverse attitude that the patient is “getting in the way of my work.”

4. Getting better. Well-designed tools can help clinicians with the prompts and check-lists that make for better care and better outcomes. Yes, clinicians are intensively trained in their discipline, and are generally very good at what they do – but like airline pilots who are very good at flying planes, they need pre-flight checklists too. The Health IT “wish-list” is to have Clinical Decision Support, oriented around the Clinical Quality Measures that matter to a given practice, be easily (yet unobtrusively) available at the point of care. If Mr. Patient is a diabetic smoker, I would want the prompts for all the diabetes-management elements (when and what was the last HbA1c, the last LDL-C, the last diabetic eye exam, etc.) as well as a prompt for discussing smoking cessation, in front of me as I see the patient.

The view from the health care delivery system
As a system, health care delivery is about taking care of populations. Individual clinicians take care of individual patients one-encounter-at-a-time, though as we transition to better coordination of care, clinicians are increasingly being asked to think in population-terms as well.

What do we need from Health IT that will improve the wellness of a population as a whole? Are there lessons we can learn from settings where effective population-based health care management has been successful?

Though multiple ways of categorizing our national health care priorities have been published, these might be boiled down to the following areas (in which Health IT can have a facilitative role): (1) improve health care coordination between the various settings where patients receive their care, (2) engage patients and families with their care, (3) reduce healthcare disparities, (4) improve public health safety and population health, and (5) assure privacy and security of individual personal health data.

1. Coordination of care. It goes without saying that health care is delivered not just by individual doctors, but by collections of places which have historically operated in separate silos. Health IT has the challenge of linking those settings of care together, so that needed information is available at the time it is needed. Patient-centered permission needs to govern this sharing of data, of course, but linking the system together in an easy, low-cost and seamless way – not the “tower of Babel” that some approaches have resembled – is an immediate challenge to Health IT.

With a “closing the loop” of data between referring and recipient health care providers, minimization of waste and duplication (and avoidance of errors) becomes possible. Formal structures, where clinicians can come together (in a collegial peer-review setting, with the protection from discovery that is implied by that) and discuss best-practices become possible to build. This is the idea behind “true care management,” and likely various formal runs at this notion (e.g. ACOs, modern managed care, PCMHs, etc.) will take place – however a modern, connected Health IT infrastructure is needed in order for this to actually be successful.

2. Engage patients and families. Health IT has an obligation to meaningfully connect patients with their health care providers – this means viewing appropriate summary information contained in their doctors’ charts, as well as being able to collect self-reported and device-reported information and share it with their clinicians. There is a powerful trend to share one’s health experiences socially with others, and Health IT has the challenge to provide the proper platforms for this in ways that promote individual and community health.

3. Reduce disparities. Health IT, as a facilitator of quality health care, can be priced out of the hands of those who render care to the most needy among us. Racial, ethnic and socio-economic disparity are challenges to health care delivery. Health IT tools need to be based on business models such that the “best of breed” of tools can be in the hands of everyone, not just those with privilege. We are witnessing such a trend with the growth of free, web-based health technology tools. There is still much work to be done.

4. Improve public health. The use of de-identified health data to understand the basis of disease, population trends, and disease outbreaks is extraordinarily important. Identifying unforeseen problems with treatment modalities – whether that means post-market drug surveillance, or testing the efficacy of a new surgical or other treatment intervention – is something that modern, connected Health IT must deliver.

5. Assuring privacy. Health data is sensitive, arguably even more so than one’s own financial and banking data. Making sure that an individual’s health data remains secure, that risks or “opportunities” for unintended health data breach are identified and minimized – these are the continual challenges to Health IT. The Health IT sector has an obligation to create a trusted environment that the public can use, and can trust.

Conclusions
This has been a fairly high-level view of the vision needed to create modern Health IT in the upcoming year. It is a bit of a “Santa’s wish-list,” but it is also achievable. As builders of health technology, we need to keep focused on our mission – to provide the tools that health care needs in order to evolve into the kind of system we all want and need. For the individual clinician, it is the promise of high-touch high-tech health care, where the “system” does not get in the way of personal, compassionate and excellent service. For the system as a whole, it is the promise of an interconnected, data-rich and data-driven health system that provides the right care in the right form to the places where it is needed.

Let us not forget the two guiding principles: (1) keep the patient first, and (2) help those who help others. If we build it right, all else will follow.