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Problems for patients. Although at any given time most people don’t have health problems, they hear horror stories from friends and family about the financial impact of an unexpected health problem. An emergency room visit may have resulted in an unexpected bill, or a prescription medication may have an unaffordable price tag. With high deductible health plans and narrow networks, having insurance hasn’t protected people from unexpected, unaffordable costs. Even with the high cost, patients may not have clinicians available when they need them. They may feel that they don’t get enough time for a real conversation about their problems when they take time out of their busy schedule to get to an appointment.

Innovation as evolution. So often we see “innovation” as a one-time event, but it usually happens over time. But can you plan for evolutionary innovation? The American College of Cardiology (ACC) spent over a year engaging their stakeholders from multiple disciplines, patients and caregivers to develop a comprehensive roadmap for innovation.¹ Transitioning from horses and trains to widespread use of automobiles took new infrastructure development, navigation tools, rules of the road to ensure safety, consumer education and a paradigm shift in thinking about travel. Likewise, transitioning from fax machines and paper to digital systems and tools involves changing communication expectations (clinician to patient, clinician to clinician and among the professional organizations), data acquisition and use, research practices, roles of patients, payers, clinicians and caregivers, financial and legal concerns and more. Change will not happen overnight, and it won’t always be predictable. I believe that ACC is to be congratulated for its work to identify in advance the variables, plan for their potential interactions and identify goals of patients and clinicians that will smooth the transition and result in better outcomes. To make this happen, the ACC brings together multiple disciplines and patients to create an Innovation Collaborative to support innovation research for improved patient care processes and more empowered patients and clinicians.

At a recent Minnesota HIMSS meeting, one of the speakers said that blaming EHRs for burnout was scapegoating, and that physicians had experienced burn out and were committing suicide long before EHRs were in use.¹ Reports in 2017, however, have shown the time spent on EHR documentation, clinician attitudes regarding documentation in EHRs and self-reported satisfaction among physicians with EHRs they use today. The results are grim – time spent on documentation is burdensome, physicians are not satisfied with EHRs and some even plan on leaving the practice of medicine for new careers.

The changing role of patients. Although healthcare systems have been structured the same way over the past several decades, clinicians and patients are changing expectations of their roles in delivering and receiving high quality care. Patients want more information about the financial cost of treatments and medications. They want to compare prices and decide what and where to make their purchases. Patients are also more aware of quality and safety issues. A recent survey by the Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) found that 21 percent of Americans have experienced medical errors, with another 31 percent who report that people they know have had this experience.¹ Care, whether in and outside hospitals, is getting more complex, and that complexity brings with it more risk.

Prehabilitation for improving surgical outcomes. Although nutritional status and physical strength have long been known to predict surgical outcomes, opinions varied about whether you could improve outcomes by addressing these factors. In the past decade, research has been undertaken to determine (1) which interventions improve outcomes; (2) which patients are candidates for intervention; and (3) which indicators measure improved status and correlate with improved outcomes. In addition, recent research has explored when the best time is to intervene – before surgery and/or treatment (i.e., prehabilitation) or after (i.e., rehabilitation).

Long-term care providers left behind. In the last decade, most of the work digitalizing healthcare has focused on hospitals and physician clinics. Incentives for adopting digital systems and tools bypassed nursing homes and home care providers, leaving them without a way to easily share data with hospitals and physicians. In spite of this, requirements to work more closely with hospitals and physicians increased even while reimbursement was reduced. To safely care for their patients, home care agencies and nursing homes were often asked to digitally integrate with several clinics and hospitals – something difficult and expensive to do. As a result, the fax continues to be the technology of choice to exchange health information. Accountable Care Organizations (ACOs) encounter these barriers that make sharing data with community based organizations difficult, making outcomes more difficult to measure and improve.

Clinicians have become more vocal about frustrations using electronic health records (EHRs). Some articles have generated solutions, while others invite further discussion. In his article published in the New England Journal of Medicine, Allan Goroll suggests that changing payment schemes to “pay for outcomes” rather than “pay for processes” will result in fewer billing-related documentation requirements and better information for driving good decisions. His “pay for outcomes” is substantially different from the proposed “pay for value” plan that he says “relies even more heavily on EHR documentation and rewarding achievement on process measures” and doesn’t “correct the misplaced emphases on care processes and service volume.” John Levinson and colleagues, on the other hand, announce their intention to hold town hall meetings to discuss the problems they identified and announced on WBUR, Boston public radio and published in CommonHealth. They ask that administrators and clinicians work together to get better systems and ask government to re-think their requirements to fix the current systems that are “the medical equivalent of texting while driving, sucking the soul out of the practice of medicine while failing to improve care.”

Mixing healthcare and legal services is often viewed as mixing oil and water, but healthcare providers are finding that legal problems can hinder patients from achieving optimal health. The National Center for Medical Legal Partnership is spearheading an effort to link patients with health-impacting legal problems with legal resources. Here in Minnesota, the Upper Midwest Healthcare Legal Partnership Learning Collaborative promotes collaboration between healthcare and legal service providers in Minnesota to improve health and reduces overall healthcare costs. Their 2nd annual meeting was held earlier this month in St. Paul, highlighting several clinics’ pioneer efforts to impact their health.

An interesting paper caught my attention describing the prescribing patterns of short-term corticosteroids and the incidence of adverse events in the 30 days after their prescription. The results were surprising, and I wondered why such a large number of patients, roughly 20% of this insurer’s beneficiaries between 18 and 64 years of age in a 3 year period of time, received this therapy. They found that it was usually prescribed by primary care (family medicine and internal medicine), although emergency medicine, otolaryngology and orthopedics specialists also prescribed it less frequently. This retrospective study based on claims data showed that those who received these prescriptions experienced significantly more adverse events, including sepsis, venous thromboembolism and fracture, than those who did not receive these prescriptions. What should prescribers do with this information? Does it mean that patient risks outweighed benefits for short-term corticosteroids? If it provides benefit, can the risk of an adverse event be accurately predicted in individual patients?

Pressures to improve care at lower cost. Higher healthcare costs are creating pressures on those who pay – government, employers, insurers and individuals. Most recent efforts have not reduced and sometimes have increased costs, and treatment advances have added more costs for cancer and other serious diseases. What strategies are left to improve care for patients while reducing overall expenditures? Ways to better coordinate and communicate are being investigated, one of which is using multi-disciplinary, interactive and longitudinal Care Plans for patients to co-create and use outside institutional settings.

A Healthcare.mn http://www.meetup.com/healthcaremn “Senior Care Ideathon” meetup in Minneapolis brought together providers, entrepreneurs, advocates and healthcare business professionals to address specific issues facing the American healthcare system in the next decade. The goal of this “Flip the Nursing Home” exercise was to bring ideas from multiple sectors to mash up ideas about how technology can be used to deliver safer, more efficient care to patients in their homes.

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There are many reasons for making collaborative, patient-centered care work better, and organizations are beginning to talk about them. For chronic conditions, a multi-disciplinary team can provide more comprehensive care than a single clinician. New technologies, including Datuit’s, are making it easier to communicate, collaborate and share information among team members and with patients and caregivers. Patients and clinicians alike are starting to realize that more information from more sources can help them improve health and avoid the consequences of poor communication.

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Before Electronic Health Records (EHRs) were widespread, politicians said we needed them so that when we are in an Emergency Department (ED), clinicians will have our health information available. Today, most hospitals and clinics use EHRs, but it’s been more difficult than expected to make your health information available in an emergency. The American College of Emergency Physicians (ACEP) Council investigated health information exchanges and made recommendations to improve the information available and the manner in which it is presented to facilitate better ED care and lower overall healthcare costs.

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Did anyone predict when Meaningful Use was conceived that in 2015 the federal government, payers and providers would be pushing the reset button? Yet starting in 2014, indications were there that Meaningful Use as it was conceived was not working. Physicians weren’t happy. Contrary to what Congress was promised, costs were not reduced nor was quality improved. Gains, if any, were minor, and projected costs continued into the foreseeable future. A high profile report recommended utilizing new technologies. So in 2015, a new roadmap was published; new Chronic Care Management payments are promised; and, of course, the finger pointing continues.

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Most people don’t have serious health conditions, but most of us have close friends or family members who have or have had conditions involving multiple healthcare professionals and caregivers, often with multiple organizations. The 20th century brought advances in medical care, including the discovery of vitamins, development of antibiotics and advances in surgery. In the 21st century, advances in communication and information management are changing the dynamics of clinician-patient-caregiver relationships, giving more importance to patient preferences and involvement in their own care. As we strive to manage healthcare costs and improve the patient and caregiver quality of life, better information technology is being developed to make that happen.

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Background: Medical Documentation Now and Then. The transition from paper to digital medical records has occurred over the past few decades, with an acceleration fostered by HITECH passed in 2009. Eligible providers were granted incentive payments for adopting certified Electronic Health Record (EHR) systems. Through three stages of Meaningful Use, healthcare providers were expected to use EHRs to improve the quality of patient care. In the process, documentation expectations have changed, and many physicians report concerns about care delivered to individual patients and populations as well as patient safety. They believe that medical documentation has become captive to requirements that cloud the narrative necessary to support the delivery of care, especially of complex, chronic care of patients with multiple clinicians.

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In 2014, “patient engagement” was a topic of conferences, presentations, white papers, journal articles, and meetings too numerous to count. Another theme has been “interoperability” – among various healthcare providers and between clinicians and patients. Is there a connection between these two concepts? The latest JASON Report, “Data for Individual Health,” brings together the needs for better health information technology (HIT) and the rationale for allowing patients to access information and to communicate with clinicians. Not only is this necessary for each patient’s optimal health, but it is also necessary to gain important understandings of better and more efficient ways to deliver care.

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Reports of savings and lack of savings from the first Accountable Care Organization (ACO) pilots have led payers and policymakers to think about what is needed to reach their financial goals. To that end, the Office of the National Coordinator (ONC) released a report, Health Information Technology to Support Accountable Care Arrangements. It gives a detailed description of the technology needed to successfully implement an ACO. Even though the first ACOs had Electronic Health Records (EHRs) implemented in most of their clinical settings, the capability to facilitate coordination across multiple providers and to utilize the data to create more system efficiencies and improve clinical outcomes has proven elusive. That capability is what Datuit has developed with its technology.

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For the past several months I have had the privilege to work with patients, families and care providers at the University of Minnesota Medical Center where we embarked on piloting OpenNotes. Acknowledging that we were likely the first hospital to attempt giving patients and families access to their medical notes throughout their stay, we employed both quantitative and qualitative approaches to gauge how increasing access would impact the MICU and MED-SURG services.

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