Rethinking Healthcare Technology

A truly patient-centric health system would let patients own their medical records and have immediate access to their results, their medical images, and their notes. They could take it all with them to plug into the different electronic health records systems as desired. Doctors would contribute, save a copy, and return it back to the patient.

To ensure that digital health systems provide value to the people we serve, we need to flip the paradigm and give more power to the patient. This would make it easier for them to receive care when they want to, not based upon the hours that a health system or a clinic runs. It’s also a great way to remove some of the burden on the health system and the physician.

My team and I are just starting to look at this from the perspectives of compliance, security, and the ability to maintain the transactional nature of the record. As a physician, I understand the medical culture. I have run a large IT shop and understand the inner workings of the IT department. I’ve also been on the hospital operations side so I understand how a health system and a hospital runs.

Which is why I believe we need to provide care where our community needs it, from clicks to bricks. We have to be available online, whether our patients are sitting in their home watching TV, or in a movie theater, or at work. But bricks matter too, because you will never be able to do a heart surgery or a valve replacement or a hip repair virtually.

This paradigm change raises the question of privacy. Right now, the health system is accountable for privacy of medical records. If the patient becomes the steward of the data, they own the privacy as well, including what they divulge and what they decide to do with the data.

Privacy differs across the generations, with baby boomers more protective of their health information and millennials more willing to share. And where is the line? There are different grades of privacy now, too. I might divulge my medical records by telling my Facebook friends that I’m in bed with a sinus infection. But if I were diagnosed with metastatic brain cancer, I’m not necessarily going to put on social media that I have a terminal disease.

The issue of speed comes back to the patient as well. The only way we are going to get health systems to move more quickly is to refocus on who our true customer is. Until now it has been the physician, but it must be the patient.

People have said that health care is behind the times in technology. I would disagree because we have the most cutting edge medical technology in the world. When the medical field realizes the clinical benefit of technology, it is adopted immediately. We upgrade MRIs from 32-slice to 64-slice and now we’re going to an even higher density.

But when you walk into a hospital after using your iPhone and iPad at home, it’s like walking into 2005. It is the general day-to-day capture of the patient story where we’re lagging on technology.

We have tried to appease our customers over these years and our customers have been the practicing physicians. We focused on investing in the technologies that they want – the best CT scanner, the best MRI, the best surgical equipment. We have tried to make our customers’ lives easier by selectively deploying technology that draws them in.

Now that our customer focus may be expanding to the patients, I see four factors that will drive the digital health industry to adapt new technologies to that new customer.

First, the cost of care is rising exponentially. If I can get my care on my phone, I’m going to do that before going into the doctor’s office.

Second, patients want to see how they’re doing, so aside from developing analytics for our providers and our revenue cycle and our house operations, we need apps and services for people to compare themselves to other similar patients.

Third, it gets back to consumerism. Being able to have an Amazon mobile health offering would not only improve the appeal of a health system, it would build better employee-patient engagement and so lead to better outcomes.

And finally, we have an additional customers now, the small business employers who are paying for insurance. They are looking for a value proposition to covering their employees, and they’re looking for an increased risk-sharing arrangement than has been previously employed.

A patient-centered approach will not be an easy shift to make. We still have resistance on the open notes initiative, letting patients see the visit or clinic notes that health care providers include in medical records. The transformation of care is only going to come when we truly let the patient in to make some of these critical decisions.

But now the field of digital health systems is in a state of flux, and there is great potential to improve the physician experience. We need to work to ensure that technology can help, and not impede, that experience.

The work of the physician has always been about making good decisions that are informed by the specific circumstances of the patient in front of you. Ideally as a doctor you have a conversation that takes the patient through what’s wrong and the various treatment options. You have a data source, and it would be nice to have a little genetic information as well.

We need this relationship to be at the core of any technology we introduce. I think it would be great to go into a room with a patient and have the conversation recorded. You would verbalize the physical exam, do some medical decision-making, develop a plan, and educate the patient. Then an extract would go to the patient, with various links helping them to digest that information. When you get back to your desk with the list of patients for the day, that conversation is right there. You validate, tweak it a little bit, receive and act on any clinical decision support, and then you’re done. What we do now is we have that conversation with the patient, and then we come back out and do it again to fill out the records.

That gets the documentation out of the way of the doctor doing what they do, which is making decisions. Carefully bolting on smarter technology is how I see IT playing a role toward bringing the joy back to the workflow, and giving physicians more control over the tools that they’re using.

The opportunity to improve the physician experience is more likely to come from digital and mobile solutions than the large vendors running our systems for electronic health records. I think we’re going to use the big vendors to run the general business, of course, but go externally to specialty firms for add-ons and extensions to do this work.

I don’t think big vendors are agile enough, particularly when you have multiple moving pieces. I’m seeing this in my own work at the University of Kansas Medical Center, where we are in the midst of a big project with a number of initiatives around redesigning our ambulatory support structure.

Interoperability is a huge challenge, even starting with some core questions like what patient are we talking about? I’ve seen a statistic that if you’re talking to a Mary Smith, there’s about a ten percent chance she is not the Mary Smith you think she is. With human frailties and technological limitations involved in collecting information about patients, it’s hard to ensure you are tying all the different versions together.

Medicare and insurance companies can take big strides toward fixing inoperability by just stating, for example, that they are not going to pay for an advanced imaging study on the same body part within a month of one another. Suddenly providers are going to figure out how to look at each other’s exams. We should think about how to start aligning incentives to promote innovation and a new way of doing things.

Until now, we’ve treated our patients as one size fits all when it comes to digital health technology. We as physicians know how to modulate our vocabulary to our patients, because we’re trying to communicate rather than talk at people. So how do our systems and our entire enterprise start to figure that out?

An intriguing approach is to stratify patients and then tailor the technology. We’re going to have about 10 more years before old geezers like me are out of the decision-making seat, and we’re starting to compete for digital native patients. The twenty to thirty year olds that are starting to become our patients don’t even know what a travel agency is. That’s going to be interesting as they become health care consumers and decision makers.

We need to think more like a retail business. In clothing sales, you can now see a virtual reality display of what a shirt would look like if you were wearing it. That’s a much more digitalized retail experience than just pictures of somebody that looks like you. We need to be figuring out the health care equivalent of the salty snack crowd vs the fitness crowd. I don’t think we can treat patients who don’t have a single book in their house the same way you might treat a university professor. I don’t in the office and we must not in the enterprise. Same care standards but delivery, interactions, etc. must vary.

When you modulate your approach to technology based on patient stratification, you know what tool is best to the gear heads, and what works for those folks who spend their time reading.

Upstart technology firms are well placed to do this. I think the big vendors are ripe for disruption, and there is evidence they are starting to pay attention as well. I’m optimistic we will soon see technology that will redirect our focus to the doctor-patient experience.

Now having created a new practice model for ADHD in working professionals outside of the limitations of general insurance, I have a much more personal and powerful role in shaping the technology and designing the products I need. Instead of paying hundreds of thousands of dollars for consultants to do it, I’m bootstrapping different technologies for things such as online patient scheduling, electronic health records, electronic prescribing, telehealth capabilities, and patient engagement and outcome tracking tools.

Innovation does not come from looking down the street to the next hospital or clinic. Taking a page out Fred Lee’s “If Disney Ran Your Hospital: 9 ½ Things You’d Do Differently,” I am now able to look towards other customer service fields for ideas. Playing with various online scheduling, videoconferencing, database management, and reporting systems, I quickly learned that the most robust and best solutions were developed outside the healthcare industry, from hair salons and dentist offices to banks and Fortune 500 companies.

As my Envision ADHD patients choose to go outside of their general insurance to see me, I need to innovate and bring a worthy experience. And I’ve found patients eager to provide feedback which makes them feel they have a crucial part in shaping their care delivery.

I realize that not every health system can experiment like we do. But whether you are working at a small mental health clinic or a major metropolitan hospital system, some level of physician-lead innovation is crucial to job satisfaction and to fuel future improvements in patient care.

So what is holding healthcare back from innovation?

One problem is that physicians are now predominantly employees, no longer involved in contracts or larger decisions and merely cogs in an ever growing machine. Early stage healthcare technology companies are initially eager for physician feedback and involvement, but once a large contract is signed the emphasis understandably shifts towards the customer (the healthcare institution signing the check) and away from the actual user (the physician/staff). When we check ourselves out of being a customer, we lose our voice.

Another problem is that the economics of sunk costs are not well understood. Hospital systems all purchased expensive electronic health records from large vendors, and they are wary of bringing in new ideas from small start-ups. The general mentality is that we’ve already spent so much, we can’t change now, but it’s ultimately much costlier to implement changes into the health record system, compared with building it first on the outside and then folding it in.

Our fear of security is probably the key challenge that holds us back. Yet the banking industry is light years ahead of us in using technology. We require high levels of security because healthcare records get targeted for identity theft.

I would argue that the Health Insurance Portability and Accountability Act must be changed to allow for innovation. HIPAA sets the standard for protecting sensitive patient data, but it’s a loose set of regulations that drives up the cost of anything IT related because of the risk of penalties if someone finds that a piece of paper wasn’t signed. We need to have standards for exactly what HIPAA-compliant means so we can focus on the actual security and less about paper trails.

The general conception in the public is that there is a single health record, but there is no one common way to view a person’s information. Some of the best examples are at universities where students can swipe an ID card and all their information is brought up for them. There are projects in the works in some states to try that for Medicaid programs, but why are we experimenting on the most vulnerable populations?

We often try things out on the vulnerable populations, the veterans, the homeless, the under-insured, those in poverty who don’t have a choice to have a good care. We take a lot of federal and tax dollars to be able to do that.

But I’ve found that a lot of innovation is coming from experimenting on the rich. We should build a universal network where rich people can control the management and transmission of their health record and take it wherever they want to go. And they would pay for this project. Obviously, we’re not going to build the perfect product right away, it will go through iterations, but once you get it right, then you take taxpayer dollars and build it out.

The rich are like the canary in the coal mine, showing us where things are going. There are now direct primary care models completely outside of insurance and people pay monthly amounts just to have increased access. People are opting out of Medicare and Medicaid because they are starting to find out that 22 signatures for one patient is just not worth it.

There are doctors in Silicon Valley whose patients are heads of the tech industry, and they operate in cash only. They pay to not use health record systems because they know those get targeted by identity thieves.

We should be looking at what people do with their care when they can afford anything they want, and know about technology better than anybody else. And we should work with them to experiment like crazy, to make sure the best innovations lead to the best healthcare we can provide to everyone.

The most important lesson is that health systems designers got the audience wrong. They focused on accountants, not physicians. The software packages are designed from the perspective of the financial folks who want to capture every charge, but that’s not necessarily what the people face-to-face with patients see as valuable.

There is a massive conflict between the care of patients and the business of health care. We need to put decision-making on digital health technology back in the hands of doctors and nurses make sure they are equipped to focus on patients.

Health is a huge industry, and like any other form of commerce, the people handling the money are calling the shots. The less connected a manager is from the actual activities in the clinic, the harder it is to know what’s important for the care aspect of what goes on. You find administrators pressuring doctors to see more patients, and doctors refusing because they have a different set of metrics. This ground-level understanding may be the reason why the best-performing health systems are the ones led by physicians.

From a business perspective, it is tempting to treat digital health like a mechanical system, and the patients are the items on the conveyor belt. The mechanical system seeks to optimize performance based on everything being predictable, but the item on the conveyor belt – a human being – is the least predictable thing in the world.

A physician speaking with a patient about a heart condition knows the risk factors and what medications would be best to try first, but every person has psychological overlay. When you ask a question, you can’t predict how long the response is going to be. And if a person’s anxiety, as well as their heart disease is not addressed, they’re going to come away saying, “I got horrible care.”

The business of health care is increasingly focused on data and analytics to make decision-making more efficient, but the practice of health care is about people, and there is no consistency in how they age, and how their health advances or diminishes.

Think of two grocery stores across the street from one another. The ideal customer is somebody who comes in, buys high-margin items, doesn’t require any help, and is friendly and nice. That’s a predictable interaction, and it brings you a profit. Then you have an older person come in with limited mobility and compromised sight, who doesn’t hear well, and is on a fixed budget. This person takes up a lot of time, and you make almost no money.

From a purely business standpoint, you would send the second customer to the store across the street, and keep the good business for yourself. In health care, from a business standpoint, most people are healthy, the equivalent of the first customer Yet when most of us think about health care, we worry above all about what happens when we develop something that needs a lot of attention. I think this is a very important distinction.

It’s rational to use data and analytics to help make better decisions. To a doctor, data would improve quality if somebody has a complex health record, and you want to know whether there is a correlation between taking a certain medication and having a an abnormal lab value. A data management system should allow you to do a search for the lab value and when the medication was taken, and it should throw up a graph tracking each parameter.

That would be a huge benefit, and it’s doable. But all the accountants care about is that when you got the lab test, it got billed, and when you wrote a prescription for the drug, it got billed. That’s why the system underperforms. The opportunity to make things so much better is huge.

There is a saying that there are two groups of patients, those with insurance and those without. I would say that an even more important distinction is between patients with straightforward, easily addressable maladies, and there are patients with threatening, scary illnesses. From the operation of the system, those are the two groupings that matter more.

It’s great to be able to streamline care when a child comes in with an ear infection. But health care just as importantly exists for the people who suddenly find out that they have leukemia. That person is going to consume enormous amounts of your resources and a lot of people’s time, and any system that says we’ve got to have the two-minute app for everybody is going to fail.

Sooner or later we are all going to be in the small group of people with serious illnesses, and we forget that at our peril. After all, most people know that that’s where the health care rubber meets the road. The top office people need to be closer to the front line so they don’t lose sight of what their mission really means.

Digital health transformation is about to take a huge step forward. Hospitals are moving away from standardization of health care technology and the limits it imposes. At the same time, we need to create a more standardized approach to how we adopt and deploy new capabilities.

I came to UW Health in Madison four years ago to help integrate the organization and expand across the state. With a background in economics, urban planning, and political science, my role is to hire excellent technology folks and translate between the strategic direction of UW Health and the technology and information systems required to support those strategies.

We are now working on a single strategy, but we have many initiatives under way. Mobile technology will be an incredibly important part of our toolkit for making these pieces more accessible to our clinicians. They include tools for getting data from patients and their devices into our system for use by the clinicians, as well as for delivering information back to them, whether they’re an inpatient or an ambulatory patient.

There has been an IT drumbeat for some time around standardization but health care is an area where I don’t think you should standardize because it doesn’t make any sense. For example, unlike other industries, health care is not a homogenous group of people and organizations, it comprises the big systems, the little systems, and the physician offices.

We are coming out of a phase of disillusionment and trying to be realistic about what we can and can’t do with electronic health records, which represent the push to standardization a decade or so ago. If you ask a physician to go back to paper, they would definitely refuse, but I don’t think EHRs have achieved the success that was promised. We set too-high expectations for them.

With a more reasonable understanding of what an EHR can do, my team and I are focused on how to limit its use to clinical needs while adding in other features and functionalities we would like and that support our organizational mission and goals.

We are trying to think more strategically, exploring the notion of a single enterprise architecture that can serve as a platform for standardizing the deployment and integration of these new capabilities.

For this to work well, it will be important to have a process for evaluating whether or not we should build a new technology within our existing EHR system, rather than assume it’s the only option. I am not interested in throwing more money at something just because we already sunk millions of dollars into it.

We are now taking a step back and developing a governance process across both our clinical systems and our administrative systems where we take suggestions for new services and prioritize them based on our institutional strategies, our knowledge of the market, and which ones make sense to us.

We need a good way to quickly scan the market of creative new vendors out there to understand how easily we could incorporate this into our EHR platform and how easily can they maintain it. It’s a noisy space.

I’m very interested in cloud-based solutions and we’re looking to try and take advantage of that kind of platform. The hope is that service-based software will provide the agility that we can’t offer internally. Thanks to the standardization pushed by the EHR vendors, we cannot be as agile as our providers would like us to be.

Instead, our IT teams are tied down by the huge burden of maintaining the system itself, which is unrewarding work and pretty expensive. When we own our systems, every 18 months or so we spend about 28,000 person hours doing an upgrade, instead of being able to focus on implementing our own new initiatives. We can’t explore or develop the innovative ideas that our physicians would like to see.

We need to figure out how best to standardize the way we integrate and deploy new digital health solutions in a way that does not disrupt our colleagues in governance, health information management, or compliance. The last thing we need is an even more complicated ball of spaghetti that we must maintain and keep secure, while keeping regulators happy.

With such a robust enterprise architecture in place, we would finally be able to work with the agility we need to be effective.

However, technology itself is not the core problem – rather, it’s how HIT was created and deployed that has created so many problems. The gaming industry could think conceptually and translate two-dimensional board games into an amazingly fun and easy to use three-dimensional experience. In healthcare, by contrast, software designers stuck to the paradigm of the paper record, thereby limiting themselves in multiple ways. And perhaps even worse, the designers and implementers focused on having physicians do all the data entry, rather than thinking about how other personnel, or even the computer, could help in that task.

Fortunately there is still hope. Digital health technology can still make doctors happier and patients healthier if we focus on how to simplify, automate, and delegate care so that the right people do the right work. A human centered design approach will help us to start building tools and workflows that solve for quality and efficiency at the same time.

At healthfinch, for example, anything we create must make life easier for doctors and save them time. We challenge our team to automate what can be automated, delegate what can be delegated, and simplify everything else. It sounds like an easy concept, but it’s not something that’s traditionally done in the HIT world.

Take refills, as a prototypical workflow that can be optimized. A typical primary care doctor may have to respond to 10-20 refill requests a day. What if we had a smart rules engine that could assess the work flow coming in and automate the process of reviewing everything based on approved, standardized, evidence-based protocols. Then we would delegate it to the appropriate staff person to handle based on doctor approved protocols. Meanwhile, we can automate other processes, such as contacting a patient about a follow up appointment, or denying duplicate refill requests. Finally, if a refill has to be sent to a doctor, we can explain the reasoning in simple terms to ensure the doctor can make a quick decision.

This type of workflow automation would achieve what everyone says is impossible - improved quality, saving time, cutting costs, and increasing both patient and physician satisfaction all at the same time! And we know from other industries that technology can do even more if we let it reach its full maturity! It’s astounding that we let automated cars roam our streets where our kids are playing, but we continue to have inertia and barriers to letting routine workflows be automated by a computer when it can be done quicker and more safely than how we do it now.

Unfortunately, a big part of these barriers are the increasing amount of regulations and requirements that have built up over the past two decades around documentation and workflow. It has gotten to the point that studies now show for every hour of direct patient care, there’s at least another hour of extra work. As expected, the more we pile onto the non-patient facing work, the more doctors cut their patient load. A recent survey reported that typical primary care doctors saw 98 patients a week in 2011, working 54 hours a week. A repeat of the survey in 2016 found that primary care doctors had cut their weekly workload to 76 patients, while still working 54 hours – helping prove the theory that we are seeing increasing administrative work for every patient seen.

So what might we do to reverse this situation? Let’s start by making sure regulations do not get in the way. For example, the rules around scope of practice were developed many decades ago, well before we anticipated electronic medical records and computerized technology. As a result, they wind up being hard to interpret and sometimes restrictive in today’s high tech world.

The scope-of-practice laws are at the state level, so we need to lobby our state lawmakers to closely re-examine those laws. If it’s simply not clear what a doctor can delegate or what a computer can automate, they need to clarify that rule. And if a rule forbids such delegation, then maybe we need to update and adjust those laws.

At the federal level, it might be a good idea to do an assessment of the different scope of practice laws across the nation. At the very least, this can provide insight for all the states. At the very most, it might become clear that some federal regulations or interpretations should be considered.

If we want to save our healthcare system, both software designers and lawmakers need to understand that, just like every other industry, we need to be able to easily automate and delegate more activities. With doctor-approved protocols and oversight, it can and should be safe and effective and efficient to delegate more of the routine and repeatable activities that happen every day.

The future of healthcare is going to be a form of information technology empowered, team-based care approach that allows for massive scalability. In this scenario, a doctor may see fewer patients face to face, but will be enabled to take care of many more patients via their team. Of course, we also need to balance this with the fact that relationship between the patient and their providers is still very human and local. We need to preserve this sacred doctor-patient relationship, but perhaps expand it to the whole care team – saving both patients and physicians at the same time. I know technology can help us figure out how to do this and create the future we want and need.

Both participants involved in this central interaction are frustrated with the dated, user-unfriendly technology and unending paperwork that characterizes healthcare.

Technology entrepreneurs trying to help solve big problems in healthcare are similarly frustrated with how slow health systems and delivery facilities move to make decisions on and deploy new technology. Daily transactions that we take for granted now — purchases of products and services, researching or providing reviews of retail locations and service providers, or simply visualizing on a map where we need to go for our next appointment – are all seamlessly performed digitally. Healthcare can sometimes feel light years away from this kind of digital transformation; for instance, we get really excited about enabling online scheduling for our patients!

Providence Ventures sees opportunity in these challenges. We work closely with our operators inside the health system and entrepreneurs on the outside to source, enable and scale transformative healthcare solutions. We understand how hard it is to achieve meaningful engagement and scale in a healthcare system, and commit to being a trusted partner in forging progress together with our portfolio companies.

If we’re successful, we think we’ll achieve better health of our communities together. What does that future state potentially look like?

First, health systems and providers will truly engage patients as whole human beings, and be trusted partners in their achievement of health. We need to connect consistently, reliably and thoughtfully to support wellness, versus only engaging in sick care. We will have more meaningful connections with each individual, personalizing their experience with us, and fulfilling the Providence Promise that for each of our patients, we will Know them, Care for them, and Ease their way.

Second, we will reduce the enormous amount of friction that exists in healthcare transactions. So much of a healthcare encounter could be digitized and streamlined, from check-in to payment, relieving providers and health systems of reams of paperwork, and giving all stakeholders time back to perform critical actions and focus on the engagement itself, increasing quality and reducing costs. The technology exists; deploying and scaling it in the healthcare environment is the hard part.

Third, we will move the needle on the health of populations. The enormous potential of preventative care to reverse the trends of increasing chronic disease - both of the body and the mind- will be realized. Population health shifts can start to relieve the immense burden of chronic disease on individuals, families, and society as a whole. It’s the ultimate challenge, but a battle worth fighting, as optimal health is achievable.

The articles in this gallery come from many different perspectives, but they all have one thing in common. They demonstrate a passion for the work and evidence that thoughtful perseverance and creative intent will enable digital transformation in healthcare. We can make this business much better at supporting the sacred relationship between healthcare provider and patient, which is at the heart of medicine and all that we do.