2013-07-31

Could The Future Of Health Care Mean No Waits In Hospitals?

As medical treatment is impacted by technology, consumerization, and the mobile revolution, we may see a world where your doctor already knows why you’re sick and can treat you over the phone—leaving the hospitals for the true emergencies.

There’s a video featuring the Kaiser Foundation that I found one day when I was perusing YouTube for insight on how the vision of the hospital has morphed over time. The video, which projects a 1950’s glimpse of the "ultra-modern hospital" offers the promise of all things streamlined and expedited, and includes amenities ranging from advanced lighting fixtures that promise no shadows during surgery to sliding baby drawers that provide mothers with easy access to their newborns (an idea ahead of its time as far as maternal-infant bonding benefits were concerned).

When you watch this video now, more than 60 years later, there’s something comical about the predictions provided. Still, at that time, I can imagine how this vision would have seemed Earth shattering. In the 1950s, the first color televisions and McDonald’s appeared so it’s not surprising that things like remote control doors could really "wow" the general public.

Let’s fast forward to where we are today, however. As a chief medical information officer and clinician, I’m tasked with keeping my finger on the pulse of what’s happening both in health care and in the real world as it relates to advancements in technology. Now, more than ever, these two worlds are colliding. The consumerization of health care has begun and the idea of doctor as driver and patient as bystander is nothing short of archaic. Today, the clearly demarcated lines between patient and caregiver are becoming blurred as patients are tasked with stepping up to the plate and actively engaging in their own health and well-being.

As we catapult into this new era of health care, I’ve been thinking a lot about what the massive shift to value-based care—or care that’s focused on quality, efficiency and outcomes vs. volume—will mean for physicians and patients. More so, I’ve been reimagining patient care. In an effort to focus and share my vision, I’m offering my thoughts on the hospital of the future and the top three transformations that will drive the next generation of patient-centric care.

Transformation #1:Technology that Works for Physicians vs. Against Them

Issues surrounding the usability of electronic health records (EHR) continue to surface despite federal mandates that clearly state that this transition isn’t really optional. To demonstrate how mainstream these EHR frustrations have become one only needs to take a brief jaunt to Twitter and search #EHRbacklash. Part of the frustration rests in the fact that doctors are forced to fit their patient data into drop down menus and point-and-click options. There’s clearly something missing within that approach to documenting a patient story. Moreover, EHRs and the typing that goes along with them, act as a barrier between the patient and doctor. Instead of encouraging interaction and engagement, technology has become a concrete wall between patient and caregiver.

So what’s the solution? It involves taking a page out of the consumer technology world. The idea being that mobile virtual assistants, like Siri, but built with medical-specific speech recognition, language understanding and artificial intelligence could shoulder the burden of these usability frustrations for physicians. In essence, streamlining how physicians interact and navigate the EHR at the point of care, while also simplifying access to data within the layers of information hidden in the system. Perhaps most importantly, this type of intelligent virtual assistant could allow physicians to turn away from the computer or tablet and engage the patient in the creation of their own record through a conversational user interface that listens, captures and creates the digital record in a natural, human way.

Transformation #2: The Consumerization of Health Care

The Internet has put vast amounts of data into the hands of today’s generation and it’s given us the ability to access data anytime, anywhere. As a result, patients waiting for surgery are likely consuming videos and advice via YouTube and Facebook before their doctor has even taken the time to walk them through the surgery, related recovery and what they’ll need to do to get their life back to normal.

So what does this mean for hospitals? It means they need to find a way to be more relevant and integrate web-based patient education and social media in a more cohesive fashion. As a result of this need, I think we’ll see more hospitals embracing everyday consumer technology advancements that you and I have come to expect – from text-message reminders about medication best practices to easy access to digital portals that allow patients to own their health information, ask questions and actively participate as part of their own care team.

Moreover, the move to the quantified self (we all know someone with a Fitbit or FuelBand) and the rapid uptick in mHealth app adoption will further encourage patient ownership of their own health which will, over time, likely eradicate some pressure and cost from our health care system. In essence, the consumerization of health care will shift more responsibility to the patient. This will force hospitals and the doctors who work in them to find new, more social ways to educate and engage their patients in order to ensure they have the information and tools needed to make smart decisions that ultimately impact their own lives.

Transformation #3: Fewer Patients Waiting in the Hospital

Part of this movement to shift responsibility to the patient means hospitals, which have for years measured financial success based on the number of filled beds, will have to adjust to a new health care system that values empty beds and healthier patients. I know, this seems backward, and it is, which is why the government is driving change through the Affordable Care Act.

As a result of this massive overhaul in the approach to how hospitals get paid, I’m seeing an interest in new approaches to care that focus on keeping patients out of the hospital. One company driving this approach is Sense.ly, an avatar-based telehealth platform that enables continuity of care for chronic diseases, leading to improved patient outcomes and reduced costs.

According to the Centers for Disease Control and Prevention, chronic diseases contribute to seven out of 10 deaths every year in the United States. Data also shows that the largest volume of readmissions occurs among patients with chronic disease and more than 75% of health care costs are in fact attributed to chronic illness. Sense.ly helps address these systemic issues by enabling patients to manage their chronic diseases through a telehealth platform offering access to home-based behavior and medication services and consultation. The telehealth market, which is slated to impact 1.8 million patients worldwide by 2017, compared to 308,000 today, offers a glimpse into what the most profitable hospitals of the future might look like—empty.

When I think about where health care is today and how hospitals look and feel in this day and age, I think back on the 1950’s "sliding baby drawer" mentioned earlier. Mostly, I know that someday, someone in my same CMIO and MD shoes will think how silly it was that doctors actually hand-typed patient notes; that consumers didn’t know the number of steps they walked in a day or how much it actually cost to get hip surgery; and that people actually drove to see a doctor face-to-face vs. simply speaking to them over the television or computer. When I think about all of these things and the tumultuous changes impacting patient care, I can’t help but wonder what our generation’s version of the sliding baby drawer might be.

Dr. Nick van Terheyden, is CMIO at Nuance. Find him on Twitter here.

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17 Comments

  • Jim Osterman

    While I hate waiting for medical care there has to be a concern on the other side as to the quality of care if the aim is to keep the wait area clear. Tread cautiously about decisions made on patient care with speed in mind.

  • Nick van Terheyden

    -> Dike Drummond

    Thanks Dike - I agreeIn fact many of my presentations cite the statistic of clinicians burn out as a major challenge in our system as we face increasing draws on our timePatients come in to see the clinicians, not to see the clinicians interact with technology. Technology needs to provide tools that support the engagement with the patient without hindering the primary purpose fo clinical care and that clinician/patient interactionSupporting doctors to help them deliver the highest quality care and offering them tools that free up time and provide valuable support is where we need to focusThat said I would also suggest that the the profession and clinicians need to adapt as well. We resist change like everyone does and have been doing so for years as evidenced by the quote from the London Times commentary in 1834 on the Stethoscope:>>>>>That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner; because its hue and character are foreign and opposed to all our habits and associations<<<<change (medical="" adapt="" address="" adjunct="" and="" apply="" as="" back="" be="" been="" but="" certainties="" child="" clinicians="" decision="" delivery.="" doctors="" does="" education="" embrace="" existing="" few="" fo="" forgotten="" guide="" has="" have="" healthcare="" help="" in="" intelligence="" is="" it="" knowledge="" life="" loading="" long="" making="" medical="" meet="" minted="" much="" must="" necessary="" need="" need.="" needs="" newly="" not="" of="" one="" our="" part="" process="" process.="" reform)the="" students="" system="" teach="" technology="" testing="" that="" the="" they="" this="" to="" train="" up="" way="" we="" well="" with="" work="" workers=""></change>

  • Nick van Terheyden

    Thanks for the comments - yes there are many additional avenues and maybe we won't see the demise of the bed...but I do think it will not be the central theme in healthcare. As it is much of our "system(s)" (and I mean this broadly across the US, Europe and the RoW) is focused on admitting patients. But we know that the best care is given to *prevent* disease and early preventative Rx and care...this does not need a hospital bed or stay

    Unfortunately cost viability *has* to be part of the equation. Everyone wants everything if they don't have to pay...but someone has to pay. Current systems are akin to offering everyone a choice fo any car on the forecourt and someone else paying the price. In which case we would all pick Porsche, BMW, Mercedes, Ferrari, <insert car="" favorite="" here="" your="">. There is a limited pool of resources to treat an ever expanding group of patients with an ever expanding (and in many cases costly) new treatments. Carrying your personal record is a great idea - the implementation has been a challenge. I personally have carried my health record around for 25+ years. It started as pieces of paper and has morphed into files on a laptop but its my record and I have had trouble sharing it with anyone effectively aside from printing and handing it over</insert>

  • GubfunckelC27

    1/ technology for health records is here, but not integrated; one Trust cannot readily access another Trust's patient records and rely upon paper copies; the reason is basically a lack of proper investment in appropriate technology, it is led by cost and not quality.
    We could also develop bands for patients to wear indicating that a known problem such as diebetes, heart rate, liver / kidney function is failing so they respond for medical care more quickly means getting treatment before it is a disater; that is a good use of patient monitoring2/ patients owning their own healthcare issues, with relevant information being passed using simple technology, used as reminders for appointments, or for prescriptions or taking of medicines would help; we have phones that can do most of that and passing it to a healthcare person is creating a massive admin problem.
    3/ as to patient beds let us rethink again, we need patients to be cared for, they need to be properly checked and released when able to fend for themselves so getting clinical excellence is essential, and some of that may be in preventative measures but they still need beds; when in hospital simple care is missing because staffing levels are low, one Hospital inManchester has above national rates for staff to patients and has shown that works because they have the lowest infection rates in the Country; they cannot manage with those staffing levels and will see changes when they start reducing them as they indicated they must because it is not cost viable.Cost viability in patient care should not be the deciding factor, proper care should an having proven that :correct: staff levels are above those indicated Nationally then that should be the target, if it means patients spend less time in hospital, have less risk of infection and therefore a reduced risk of ward closure then it must make cost sense, especially if Hospitals are to be fined for not meeting care targets.
    I amnot sayingmy views are in any way correct, just that here has to be a focus on patient care once invited into Hospital as that is where the treatment is provided when the patient is at their lowest level of resistance.

    HW Scott
    a long term patient and NHS employee 

  • Nick van Terheyden

    Thanks for the comments - yes there are many additional avenues and maybe we won't see the demise of the bed...but I do think it will not be the central theme in healthcare. As it is much of our "system(s)" (and I mean this broadly across the US, Europe and the RoW) is focused on admitting patients. But we know that the best care is given to *prevent* disease and early preventative Rx and care...this does not need a hospital bed or stay
    Unfortunately cost viability *has* to be part of the equation. Everyone wants everything if they don't have to pay...but someone has to pay. Current systems are akin to offering everyone a choice fo any car on the forecourt and someone else paying the price. In which case we would all pick Porsche, BMW, Mercedes, Ferrari, <insert car="" favorite="" here="" your="">. There is a limited pool of resources to treat an ever expanding group of patients with an ever expanding (and in many cases costly) new treatments. Carrying your personal record is a great idea - the implementation has been a challenge. I personally have carried my health record around for 25+ years. It started as pieces of paper and has morphed into files on a laptop but its my record and I have had trouble sharing it with anyone effectively aside from printing and handing it over</insert>

  • Dike Drummond MD

    Great article and what is needed for your 3 transformations to take place is a fourth you don't mention. The missing piece is the organizational health of the business providing the majority of healthcare in the near future. Consolidation is happening at breakneck speed even now. We will be relying on large regional and national provider organizations to make all of this happen. That is a problem.

    The defining features of the vast majority of today's healthcare organization are
    1) A toxic workplace where one in three doctors suffer from burnout on any given office day
    2) Silo's between the administration and clinical wings that make the adoption of innovation extremely difficult in most cases
    3) An absence of physician leadership. The docs are hanging on by their fingernails and "just want to see patients". Even if there were functional physician leadership in place, it remains to be seen if they would be granted board room access.

    Here is the fourth transformation you don't mention ... an advancement in healthcare organizational development and physician leadership to produce an organization capable of disseminating the three transformations above. This "soft skills" revolution (the "creative destruction of burnout" if you will) is never mentioned .... and key to any tech based innovation.  Otherwise you are building your beautiful future on a foundation of compost.

    My two cents,

    Dike
    Dike Drummond MD
    TheHappyMD (dot) com

  • Nick van Terheyden

    Thanks Dike - I agree
    In fact many of my presentations cite the statistic of clinicians burn out as a major challenge in our system as we face increasing draws on our time
    Patients come in to see the clinicians, not to see the clinicians interact with technology. Technology needs to provide tools that support the engagement with the patient without hindering the primary purpose fo clinical care and that clinician/patient interaction
    Supporting doctors to help them deliver the highest quality care and offering them tools that free up time and provide valuable support is where we need to focus

    That said I would also suggest that the the profession and clinicians need to adapt as well. We resist change like everyone does and have been doing so for years as evidenced by the quote from the London Times commentary in 1834 on the Stethoscope:

    >>>>>That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner; because its hue and character are foreign and opposed to all our habits and associations<<<<

    Change is one fo the few certainties in life and we have to embrace it and help guide the process. But as part of that we must adapt the way we teach and train our doctors (medical education has long been the forgotten child in much of the healthcare reform)
    The system of loading up medical students with the necessary knowledge and testing that knowledge does not meet the need. THey need to be knowledge workers and work with adjunct technology to apply intelligence and decision making to the process of healthcare delivery. And this needs to be address back to existing doctors as well as our newly minted clinicians

  • David Fairbanks

    Nick,
    I appreciate your vision.  But it lacks the reality.  Although I do treat some patients who are concerned about their health on the internet, most of the patients I see in the emergency rooms across the country and on Native American reservations care very little about their chronic diseases.  They ignore my pleas to quit smoking, stop using, stop drinking and eat better.  They refuse treatment for correction of their chronic diseases and only want the immediate consequences of their resultant pain to be taken away.  

    We live in a society where the majority of individuals we are supporting through entitlement programs, including health care, are instant gratification seekers and think little about the future. The subsequent generations they are raising are learning these maladaptive behaviors.  How can we hope to control diabetes, hypertension and heart disease, when toddlers are drinking Mountain Dew from bottles and children are eating two bags of chips, two frozen pizzas and a liter of Code Red in front of the TV after school?  They are doomed to obesity like their 400 pound mothers, some before they get out of middle school.

    When I was a young man, I had visions of serving as a doctor on the Starship Enterprise, where I would have voice recognition computer that would enhance my doctor patient relationship and the technology to cure disease through a biofilter on the transporter.  But "Dammit Jim, I'm a Doctor, [not a politician, not an inventor, and] not a magician."  I can only hope to influence the system one patient and one encounter at a time.  

    Dave Fairbanks, MD

  • Beacon Urgent Care

    Are Urgent Care centers not already accomplishing some of this? Telemedicine, web-based patient/doctor portals, ...

    The future is here! ;)

  • futuredoc

     

    Dr Van Terheyden,

    Excellent article. All three of your visions
    need to occur and presumably will albeit in fits and starts. A big problem with
    the EHR, as you note, is that it is not built for the practicing physician.
    Rather it is built by computer programmers that have never walked the halls of
    a hospital or sat in an exam room to understand how a physician actually works.
    Today, it is a time waster and it distracts – the doctor is looking at the
    screen rather than the patient. This loss of eye contact leads to loss of intimacy,
    trust and prevents deep listening. And as you point out it does not save time.
    I am aware of one company, Salar, Inc., (that was for a while part of Nuance,)
    that takes a much different approach. They sat in the hospital wards with the
    docs until they understood what was needed. To date, physicians actually like
    to use their system.

    You are right on about the consumerization
    of medical care. Medicine is still provider-oriented but will have to become
    patient-oriented. “The patient will no longer be patient.” They want and will
    expect short times to an appointment, courtesy, professionalism, short wait
    times, and a real effort to level the information playing field.

    Chronic illnesses have far outstripped
    acute illnesses although our system is fundamentally geared around the old
    model of caring for acute illnesses. Certainly more and more will be done as an
    outpatient but the rapid rise of chronic illnesses will ultimately mean the
    need for more ICU beds, more sophisticated ORs, more interventional radiology.
    And it all costs a lot of money for the complex imaging, equipment and of
    course the EHR (that doesn’t do the job yet) which will be a great financial
    strain, especially for smaller hospitals driving them toward mergers with large
    systems.

    To your list I would add the shift
    toward employed physicians by the hospital. A major change. And the shortage of
    primary care physicians with no end in sight.  And those PCPs in practice seeing far too many
    patients per day to have enough time – time to listen, to prevent, to coordinate
    chronic illness care and to just think. I believe that it will only be when PCPs
    can again take the time needed that costs will ultimately come down since PCPs
    can be the valve that recommends tests, imaging, procedure and specialists.

    Stephen Schimpff, MD

    The Future of Health Care
    Delivery - Why It Must Change and How It Will Affect You.

  • Nick van Terheyden

    Thanks Steve - appreciate the feedback
    Yes there is a shift to the employed doc and the downside to this is the "production" model that takes away time with patients and tries to squeeze more "efficiency" from our interaction
    My hope is that some of the consumerization will off load this work load and reduce the interaction with doctors to the ones that really need to take place.
    I know my next comment may be seen as heresy but....
    I don't believe a patient with a sore throat needs to be seen by a doctor (every time or certainly in the first instance)..let alone in the ED
    But the system pushes this and in some instances the doctors need/want thsi as it is part of the services they provide and are  reimbursed for

    Elevating the doctor to the specialist and expert and having an infrastructure of technology and para-clincal staff to deal with minor issues/problems would alleviate the work load and free up the doctors time. I know this leaves a gaping hole in doctors compensation and that needs to be addressed as well. I thin the answer to this is tied to specialization but also educational costs (given the massive debt load most doctors emerge with post graduation)

  • Donald Bellefeuille

    Great article. I think what you listed is just the tip of the proverbial iceberg and many of the changes we will never see coming until they're actually here. Let's add robotics to the list while we're at it. What's a poor hospital fund raiser supposed to do now? 

  • Nick van Terheyden

    Great addition - robotics is already part of some hospitals - albeit it simple forms for transportation adn as "dumb" assistants but a good friend has already demonstrated remote surgery (telemedicine/telesurgery) and there is much to recommend the agile steady hand of a robot over a surgeon direct touch...so perhaps as surgeon extenders vs replacements?

  • Gopal K Chopra

    Music to my ears Dr. Nick - great summary of the pains, their cause and the antidote! 
    "taking a page out of the consumer technology world." of course! "find a way to be more relevant and integrate web-based patient education and social media in a more cohesive fashion" be where your patient is and respond efficiently! and "new approaches to care that focus on keeping patients out of the hospital" benefits us and benefits the patient!
    I think the real life examples of 2 & 3 are targeted conversations happening on secure channels by care management staff and redesigning the work flow so we are planning interventions and not waiting on acute crisis events that lead to arrivals in the ER!

  • Nick van Terheyden

    Thanks Gopal - agreed. You introduced the concept of pinged.com some time ago and by all accounts it receives rave reviews form doctors and patients alike.
    Not just plain messaging but pictures and real "social" engagement that is time shifted and place shifted to help both the patient and the doctor.

    Once people get over the "change" I believe they will adopt this and probably demand it as the better, more convenient and cost effective form of care.

  • think_barbara

    Transformation # 1 - that is an interesting idea. Transformations # 2 and 3 are a bit vague, more concrete ideas would be useful. The sliding baby drawer is priceless, of course!