From #HIMSS16 to #ehealth2016 – new work, new roles and a new language

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“We need the Intelligence Augmenter, stat!

“The diagnostic algorithm’s out of whack and the Transition Specialist wants to know how the interface outflow is correlating the patient’s Fitbit data into the Director of Decentralized Asset Management’s new discharge interface. And we can’t reach the Business Analyst for Patient Workflow.”

The above is not a conversation you are likely to have heard in your hospital lately.

But if you listen to Mark Casselman (@markcasselman), the CEO of COACH (@COACH_HI), Canada’s Health Informatics Association, it is the type of exchange that could be a reality in the not too distant future.

In a recent address at the #HIMSS16 conference in Las Vegas, Casselman gave a thoughtful overview of how the changing landscape around how digital health care is going to fundamentally change not only how care is provided to patients but also the roles and responsibilities of those providing that care.

Casselman noted we are currently in an environment where we have two distinct health care delivery ecosystems working simultaneously – the traditional health care delivery system based on face-to-face interactions between provider and patient in either an office or hospital setting, and the new and evolving consumer-based digital health system – the world of virtual care, apps, engaged patients and the quantified self.

“The traditional health care delivery ecosystem is mostly operating distinctly and differently from these fantastic innovations. They’re operating at different clock speeds.”

He notes that virtual care is evolving along the whole continuum from the traditional clinician/patient interface through team-based care to the new personalized patient-centred approach to care.

“It’s almost impossible for these things to be embedded in the traditional system because they’re changing so quickly,” he said.

These evolving forms of digital care and the underlying beliefs and concepts that support them are creating dynamic tension for those used to working in the traditional health care environment.

In part, he said, this is because the traditional evidence-based model of care which relies on the randomized controlled trial as the gold standard, cannot adapt quickly enough to assess and absorb the changes being brought about by digital health innovations.

To Casselman – and seemingly to the 42,000 delegates to the Vegas meeting – the new reality is one Canadian physicians, hospital administrators and all others employed in the system must start to acknowledge.

“Health care professionals, teams, and organizations must consider what novel skills and capabilities are needed to deliver virtual care effectively,” he said.

Casselman’s organization – COACH (one of the main sponsoring bodies of the upcoming #ehealth2016 conference in Vancouver) has done much to define the 65 existing roles and responsibilities involved in health informatics in Canada today and as developed a professional skills matrix for those roles.

But with the emerging digital health world, he said, there is now a need to re-examine this and determine the new roles that will be needed to provide care in the new world of health delivery.

Using artificial intelligence to augment care with algorithms, harvesting big data for insight, precision medicine, and digital care provided through mobile in the home and the community will require many different skills sets and roles –the type of currently fictitious roles noted by Casselman in my introductory vignette.

But Casselman goes beyond this onto more dangerous ground when he questions whether the patient electronic record of the future will even be the primary point around which patient care will be focused

“We’re digitizing our physiological indicators, we’re sharing them and its creating a real tension in the world of health informatics,” he noted.

Maybe the physician-owned patient record in the EMR is only a segment of what will really be needed to deliver care in the future as the patient tracks his or her own indicators and brings this to the table.

Much to think about and we can only be thankful that Canadian informatics leaders such as Casselman are giving it some thought, especially when he prefixes it all by stating “At the end of the day, it’s all about the care.”

(The summary sides from Casselman’s full presentation can be accessed here).

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A Canadian leaves Vegas (#HIMSS16)

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I came to this year’s HIMSS annual meeting in Las Vegas to find out more about the current status of patient and physician engagement in the US health care system.

As always, HIMSS came through – (if you will pardon the Vegas-type analogy) in spades. But as always with HIMSS it was too much of a good thing and attempting to synthesize what you see and hear is almost an impossible task.

First there was the language barrier. No, not that I was trying to navigate the conference in French but rather the confusion in English health care terminology between the US and Canada.

Forget about your MACRA and your MIPS and other acronyms that bewilder and confuse Canadians; we are talking about more common terms

In Canada we talk about population health in the public health sense of maintaining the health of the entire population through preventive measures. Here, well, even those at HIMSS seemed unsure even though it was the phrase de jour  for the second year running.

As Mike Miliard, editor of Healthcare IT News wrote: “Whether looking at it as a big-picture value-based care model (an ACO, a patient-centred medical home), or the nuts-and-bolts needed to manage specific segments of patients (mobile engagement tools, HIE analytics), getting a handle on the concept of population health can be tricky.”

Population health as a proxy for focusing on chronic disease management and tailoring treatment appropriately – well, sure that make sense as that’s the preoccupation with Canadian providers and health policy makers as well. Why didn’t you just say so?

Once we get around terminology, the messages out of HIMSS were more comprehensible.

Physicians remain seriously PO’d with their EHRs and what they are doing to their health and well-being. Even Andy Slavitt, acting director of the Centers for Medicare and Medicaid Services (CMS) admitted as much.

But improvements are promised and leading US physicians acknowledge EHRs are here to stay and that multiple clicks thing to do something as basic as give a flu shot will be corrected soon.

What was much more fascinating in Vegas is how the whole patient engagement field is evolving.

Discussion of patient portals has given way with extreme rapidity to acknowledging virtual care must span a whole range of apps, devices, platforms and wearables. Many hospitals are ahead of their counterparts in Canada in enabling the use of tools such as apps to improve the patient experience.

But despite the growth of the Open Notes movement and the necessary sharing of patient records with the patients themselves, an Accenture survey released during HIMSS was an eye-opener. It showed physicians are becoming less likely to support full sharing of patient records even while patients are requesting same in greater numbers. A conundrum to be addressed, surely?

And then there is the question of just how engaged people really want patients to be.

Dana Lewis, a pioneering patient advocate closed the day at the patient engagement pre-conference symposium by discussing how she hacked her devices to improve management of her type 1 diabetes. And please, she said, call her a person with diabetes not a diabetic because she is not going to let her disease define her.

Fast forward to a panel discussion later in the meeting where consultants and providers discussed innovation in diabetes care  sans patients and using the term ‘diabetic’. As with so much of HIMSS, it struck me that patient engagement is applaudable but please have more patients in the room and avoid viewing them as objects, or heaven forfend, revenue sources.

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#HIMSS16 A passing unpleasantness?Physicians and EHRs

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Finding out what US physicians think about electronic records at HIMSS16 took no longer than hearing the first speaker in the first pre-conference satellite session on Sunday titled: “The Electronic Health Record: What went wrong? Can it be fixed?”.

“The number one complaint for the quality of life and for practice is the EHR in its present form,” said Dr. Ed Livingston, Deputy Editor, Clinical Review and Education, for JAMA.

He was quickly followed by session moderator John Nosta who noted “the EHR seems to be ill. Should we put it in the ER, the ICU or the mortuary?”

This less than cheery outlook was then reinforced by Dr. Christine Sinsky, VP of Professional Satisfaction for the American Medical Association (AMA)who repeated results from a 2013 survey suggesting the number one reason for burnout among physicians was the EHR.

Sinsky then became the first of several speakers at HIMSS – including Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS) – to quote individual US physicians and their angst in dealing with EHRs.

For a Canadian observer of the physician community, all of this initially seemed a little overwrought.

Sure, many Canadian MDs complain about their electronic records systems as well, especially during the implementation phase. But being driven to burnout or actually leaving medicine because of the EHR?

What seems to be at the core of the problem for most US physicians are the data recording requirements – the sheer number of clicks required to perform and document clinical interactions.

Thirty-two clicks are required to order and record a flu shot, Sinsky notes. Eight clicks to order an Aspirin, quoted Slavitt, 16 if its full strength.

Dr. John Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston, noted physicians at Beth Isreal must make 450 clicks and enter 141 structured data elements during a 12-minute patient encounter “and make eye contact with the patient.”

Slavitt said the message from the physician community is clear: “Stop measuring clicks, focus instead on allowing technology to become a tool and focus on the results technology can create. Give us more flexibility to suit our practice needs and ultimately more control.”

The good news from HIMSS is that there appears to be a willingness to make this happen. With legislative changes in the US and a move towards outcome-based care and population health, the rigid process-based requirements – what AMA President Dr. Steven Stack terms the false sense of precision where accuracy really doesn’t exist – may fade into the background.

Furthermore, the EHR itself may become a relic as multiple platforms for providing virtual care and the growing movement of patient engagement and empowerment move the locus of patient data from the physician to the patient.

Halamka proclaimed the growth of mobile means “the desktop is dead” and he talked of Facebook-like social networking applications being better for capturing the physician-patient interaction.

All of this is being accompanied by a more realistic assessment of EHRs by knowledgeable physicians.

“Those who come into practice in 10 years won’t understand why people had been so unhappy,” Stack said.

(Photo: Dr. John Halamka speaking at HIMSS16)

 

#HIMSS16: Betting on ways to build better apps

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The woman was sitting at the casino bar at 4:30 am playing the slot machine embedded in front of her and sipping on a beer early this morning before the 40,000 plus delegates began the first day proper of HIMSS16 in Vegas.

While arguably personifying some of the worse health behaviors, the argument had been made the day earlier that perhaps her behavior was the very type policy makers and providers should be looking at to make headway with one of the more challenging conundrums of the modern health IT era – how to get people to actually use some of those estimated 36,000 mobile-enabled health related apps and wearable devices to rimprove their health.

The suggestion was made by Lygeia Ricciardi (@Lygeia), a health care consultant, during a presentation at the pre-conference symposium on patient engagement.

Along with physician and app designer Dr. Jennifer Shine Dyer (@endogoddess), Ricciardi gave an excellent comprehensive evaluation of the current status of medical apps and their value to patients.

Dyer, who has done outstanding work in designing apps to help patients with type 1 diabetes, also showed the difficulty of coming up with an app patients will use on an ongoing basis to improve their health.

“Bribing kids doesn’t work,” she said, of her experiences using rewards with adolescent patients to encourage them to monitor their blood sugar.

Now, Dyer said, she has turned to gamification as the potential route to design apps that engage patients.

Asked by a somewhat puzzled delegate what gamification means, she explained, turning the app into a game gives the user social clout, gets their mind of their condition, and perhaps most importantly is fun to use.

And it was gamification on a large scale that Ricciardi referenced when she suggested looking to Las Vegas and the casinos for truly expert advice on tactics to separate people from their cash in a way that is fun and irresistible.

When it comes to apps in health care, Ricciardi noted we are still at the very early stages of adoption. While 80% of Americans report using one or more forms of mobile apps, she said, data show only 17% of these are using mobile apps.

Part of the problem she and many others have noted is that currently apps are not well integrated into the health care system. While 93% of US physicians believe apps can improve outcomes, few are actually enabling their patients to integrate of the information gathered from those wearable devices into their care.

In addition to turning to tactics like gamification, Ricciardi and Dyer also said more good evidence is needed to show this approach can improve outcomes. And perhaps most importantly, apps must be developed that really meet patient needs rather than what the app developer or provider thinks they need.

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