Technology continues to propel the healthcare sector forward. Consider the advents within healthcare data: long gone are paper charts filled with unintelligible provider notes, instead our EMRs and various data sources backfill warehouses with terabytes of healthcare data. Data mining techniques and the introduction of artificial intelligence provide the capability of developing not only predictive but prescriptive models – with algorithms capable of near certain (data-based) prediction of patient risk and optimal pathways to mitigate those risks.

These technological advances are pivotal for providing direction and innovation in the midst of a shifting healthcare sector, from volume (per click reimbursement) to value (population-based reimbursement).  Yet, in the advent of disruptive technology, including our capabilities in data-driven healthcare, we have yet to experience a subsequent disruption in patient and community health outcomes. That is, while technological advances including the next best predictive algorithm are growing in specificity and applicability, these advances seem to be outpacing healthcare’s ability to leverage them effectively and impact fully, with measurable population-based health outcomes.

As healthcare continues to shift from volume to value – the need to identify outcomes early is crucial.

This should not come as a surprise to those of us engulfed in the day-to-day of healthcare. We’ve all been there, having dreamt up the next best advancement for our organization, working tirelessly to bolster the right support to push it forward with urgency and impact. Then the real challenge, integration into operations. How does the next best idea become integrated within the broader clinical flow of everyday health care delivery? This becomes even more difficult when we set out to effectively evaluate and to build sustainable, scalable processes around it. Similar to most tech vendors or forward organizational thinkers who appear to have the “solution”, the difficult work comes in putting it all into action. There is no shortage of ideas for predictive models, best practice alerts, or the next best machine learning algorithm. However, in standing up new technology, we often miss the mark in shifting the culture behind the tool – to make it effective, meaningful, and impactful for our patients.

The Institute of Medicine (IoM) defines a learning healthcare system as one where, “science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience.” Unfortunately, building a culture that collaborates early and often in the development, implementation, alignment and testing of new technology is a mountain most healthcare systems continue to face. Yet, in my experience working alongside healthcare administration, technology leaders, data analysts, researchers, and providers, there do seem to be effective ways of overcoming these barriers. The approaches are not earth-shattering, yet if done with intention as part of the early strategy, they may assist in breaking down the barriers for uptake and impact – those standing in the way of truly impactful technological advancement and a radical impact on the health outcomes of our patients and communities.

Communicate and collaborate. Bringing together multiple champions and perspectives not only to the technical build of an algorithm, for example, but for the potential application and ultimate goals of the tool needs to occur early in the process and consistently thereafter. Not everyone is a data scientist or tech expert, but everyone brings a unique perspective to the complex issues facing healthcare delivery. There needs to be a purposeful openness to recognizing and listening to other’s points of view very early on in the process. We’ve all been there, it’s difficult to bring in various stakeholders with impossible calendars and workplace dynamics that stand in the way, however, the upfront work is pivotal for success in backend implementation and impact. I’ve learned in more failures than I can count that identifying champions early on, long before your first data model, and keeping them close through consistent and appropriate communication is pivotal. Your executives and C-suite may not need to see the code behind the model, but they do need to be bought in early on around the need and ultimate goal. Building a tool for a perceived problem only to find out providers or healthcare leadership don’t perceive the same issue and need sets both sides up for failure.

Measure meaningful impact. Gone are the days of starting a project or employing a new tool with the assumption it will work with no outcomes backing it (at least I hope!). We have a responsibility with technology and tools built to measure impact. Technology for technology sake has come and gone, very few organizations can move innovation forward without impactful ROI– and not just dollar signs, the patient outcomes associated with it. Early on, work to identify leading indicators – those that show long before the often lagging outcomes that this solution might be working. As healthcare continues to shift from volume to value – the need to identify outcomes early is crucial.

Build alignment. Technology built for alignment – with the capability to be communicated and utilized across payers, providers, and patients – will be ahead of the game in a shifting healthcare environment. Coordination underlies healthcare success of value-based care; unfortunately, it’s still difficult to find technology solutions that assist in meeting this need. From benefit design to payer coverage to physician communication, all levers work together to move patients along with their health continuum. Tools and technology that recognize these multifaceted environments surrounding healthcare will be leaps and bounds ahead of those in silos, with singular approaches.

As the idea of value over volume inundates the healthcare sector, the success of disruptive technology hinges on its ability to provide direction and impact in the value shift. Unfortunately, we can miss the boat on leveraging technology for meaningful impact because we overlook foundational steps: collaboration and communication, measuring meaningful impact and building alignment across multiple facets of healthcare. Technology has the potential to be the catalyst for much larger cultural shifts to occur. Because of that, healthcare’s ability to leverage technology will always rely on leaders – administrators, providers, and innovators – to build a meaningful foundation to thoughtfully bring technological advances into action and impact.

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One need not have read Dr. Atul Gawande’s recent 9,000-word essay or visited a physicians’ lounge to know that doctors are not fans of the electronic medical record. Physicians yell at least as many words, unfit for print, at computer monitors each day. We live and die by the smallest incremental changes. Every downtime, planned or unplanned, sends us into a tailspin for weeks. But as health systems and physicians aim for the same destination—better care—the two groups need to be aligned constructively, despite their different routes.

The way that health systems and physicians interact can best be described as complicated. The goals and challenges are largely the same. And though sometimes the approach is congruent, most times it is about as a similar as a Ming vase and a CBGB t-shirt (both, at least, artifacts of collapsed dynasties). To promote alignment, health systems must engage providers early and often. For this approach to work, engaged but informal subject matter experts are often better than formal leaders with little direct knowledge about the process.

We used this as a guideline as we recently went through a major overhaul of our electronic medical record, which had aged over a decade more like a stale pancake than a fine wine. This project touched nearly every record in some way. We updated security profiles, changed workflows, replaced paper billing, and set up new ways to manage external provider orders. Of course, there were anxieties, but early provider dramatically calmed the environment.

We structured our steering committee to include physician representatives who regularly use the EMR. The committee included our system Chief Medical Officer and invited the acute care Chief Medical Officer, as well as the trauma and primary care medical directors, both of whom practice regularly. I participated as a clinical/IT “translator.” For additional touch points, we created a physician-specific subcommittee to work through more granular details. As the project progressed, early and frequent user acceptance training included regular users. We scheduled these meetings at times that made sense for providers—at lunch, before their OR time, or after the close of the clinic. There was a little bit of fear and a few concerns, of course, but we were able to address these in real time, long before go-live. And for items that bordered on the unreasonable, we could escalate long in advance to respected physician leaders.

The way that health systems and physicians interact can best be described as complicated.

Correspondingly, communication occurred at nearly every meeting that a provider might attend. IT staff, physician leaders, and I made frequent appearances at medical executive committees and department meetings. At a point, the communication might have become more irritating than the anticipation of coming changes, with posted signage in physician lounges and dictation rooms. And when we finally did go live, we had senior leaders rounding from pre-dawn until long after dark, ensuring that providers knew who to go to and could see that their issues were being addressed.

To paraphrase Dr. Gawande’s Chief Clinical Officer, Gregg Meyer: the EMR is not for the doctors; it’s for the patients. This is absolutely true. But it is the clinicians who use it every day. For meaningful improvements to the EMR, physicians need to be at the table. A small collection of physicians will be sitting there before you ask them. But the rest should not be ignored. Health systems need to reach out to the providers not already there.

How does a health system help them do that? It is our obligation to ask more of ourselves when we ask more of physicians and to challenge some of the standard assumptions about what is possible. We are rightly working to streamline care, reduce waste, and lower cost. We should also work to reduce documentation, put meaningful in a meaningful format at clinicians’ fingertips, and improve the stale pancake. These are multi-year efforts that can only start when we support our doctors in guiding our transformation.

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People are living longer than ever, and as the baby boomers age, providing care to an exponentially larger, complex population will place a strain on the healthcare system. Nurses are at the forefront of eldercare, and now faced with overwhelming numbers of adults managing multiple chronic illnesses, medications, and transitions in care points, healthcare organizations are exploring new evidence-based strategies to optimize their role in interdisciplinary teams. The concept is simple but vitally important: Nurses are the foundation of healthcare delivery. How can care organizations best utilize nursing professionals in the most impactful, cost-effective and efficient manner? And how can new technologies and the integration of digital health information advance patient outcomes? The answer is analytics.

Comprehensive analytics also provides the nurse with a 360^o view of the member

Top of the Licensure Strategies to Optimize Time for Critical Thinking

Whether it is an advanced practice nurse, a registered nurse in a facility, a licensed practical nurse in a provider clinic, or certified case manager in a care delivery setting, “top of the licensure assignments” (i.e., offloading less complex work from the next level above) is an increasingly popular strategy among organizations across the care continuum. Top of the licensure goals involves continual evaluation of processes to identify tasks that can be completed by other allied health professionals to help free up more time for what nurses do best: perform critical cognitive thought, assess for and identify needs, and deliver holistic care to more patients.

Harnessing Technology to Optimize Nursing Resources and Make Smarter, Safer Care Decisions

Technology adoption is a pillar to “top of the licensure” strategies. After all, technology at its core is designed to empower human performance to the fullest extent of training and capability. With an eye on improving quality and value-based care, harnessing the benefits of rapidly developing technologies is a “must do” for care facilities and organizations.

Electronic Health Records (EHR) are nearly ubiquitous in every healthcare setting across the United States and have become essential tools to promote patient safety and automate processes. EHR technologies enable efficient and secure sharing of health information across interdisciplinary teams and care facilities to prevent errors, avoid duplication of documentation, and provide greater coordination of care.

While it’s clear that EHR technology has transformed the way care is delivered, it presents significant limitations in care management workflow and in optimizing the nurse’s role in detecting physical and/or deteriorating changes in the patient condition. After all, EHR technology is designed to document care–not assess and analyze it.

Enabling the Enabler–Workflow Tools to Supplement the EHR for Care Management Workflow

The guiding principle behind care management is the identification, development, and timely delivery of appropriate interventions to produce positive clinical and financial outcomes within a given population. Utilizing predictive data analysis models in concert with EHR technologies is crucial in identifying at-risk patients – and in leveraging the nurses top of licensure skillsets.

Communication between the EHR and a care management workflow tool can drive efficiency, improve communication between all members of the healthcare team, and alleviate redundancies. It does that by delivering timely and accurate predictive risk scoring through the data gathered by the EHR and other care documentation tools. As a result, nurses and other care manager disciplines can target and engage with at-risk individuals earlier in the condition and/or disease state.

Lacking insight from good analytics, nursing skills are placed on hold as additional legwork is undertaken to identify patients most at risk. Significant time is expended reviewing multiple information sources, including payors, the EHR hospitals, ERs/Urgent care centers, other caregivers, pharmacies, and labs – assuming that that information is accessible at all. This type of administrative work is certainly not top of the license activity for nurses. Comprehensive analytics, such as risk stratification, sorts data based utilization patterns, treatments for chronic conditions, cost, medications, and more to leapfrog over the identification process and speed up nursing engagement for populations members most in need of care management intervention.

Beyond identification, comprehensive analytics also provides the nurse with a 360^o view of the member; including diagnoses, in and out of network utilization, provider/specialty visits, admission/readmission, ER utilization, gaps in care, and medication reconciliation.

All of this information provides the care manager a strong foundation to initiative care protocols. Fingertip access to comprehensive historical details, especially around gaps in care, serves to further support and educate the member on what actions are needed to maintain and improve their health.

Unleashing the power of analytical insight to reduce health risks among patient populations not only drives improved disease management, better health outcomes, and reduces overall costs for a strained healthcare system – it helps nurses function at the top of their license.

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We’ve all heard in the news, and are certainly disheartened, about the opioid crisis. According to the Centers for Disease Control and Prevention (CDC), on average, 115 Americans die daily from an opiate overdose.

There are many solutions being discussed, rightly so, such as cutting back on prescriptions to patients and providing alternate pain management plans; as well as increasing the number of addiction programs. There is certainly a role on the clinical side to addressing the crisis. But we should also consider how using technology – specifically the power of data and analytics – can help. What if we armed medical professionals on the front lines with up-to-date information about their patients’ histories with narcotics and amount of prescriptions they have received most recently?

This can be accomplished through a universal patient identifier (UPI) – a concept that is not new. Unfortunately, it hasn’t been very “universal,” despite the many reasons it should be. One reason, in particular, makes a strong case.

Beyond the opioid crisis, drug overdoses in general are the leading cause of death among Americans under 50, according to the CDC. Prescription drugs are often the culprit as they are being prescribed to individuals from multiple providers without any way for medical professionals to cross-reference the patient’s past and current drug prescriptions.

Those who are leading the charge successfully

The concept has been embraced at the local levels. According to a University of Michigan study released this year, the prescription drug monitoring programs in Kentucky, New Mexico, Tennessee and New York have significantly reduced opioid prescriptions and the dosages of those prescriptions.

But while this has proved successful at the local level, patients very often move to a different state or city or need a specialization not offered by their current medical group, requiring them to start all over with a new doctor. However, using UPI technology, patient data—and supporting patient demographic data—can be used for the common good to improve patient safety, increase quality of care and reduce mistaken identity risks.

The creation of a UPI will allow the healthcare industry to facilitate accurate information exchange to stop problems before they start. For example, the National Council for Prescription Drug Programs (NCPDP) has already started using this vendor-neutral technology to establish a cost-effective solution for national patient safety. This technology can link patient data at scale efficiently and accurately to improve patient safety and care coordination.

There are many more clinical, administrative benefits

The benefits of a UPI extend across the entire healthcare system as well, as it improves the quality of patient identities, which can have duplicate, overlapping and incomplete records. Additionally, a UPI can help eliminate incorrect medical treatments; deliver current and accurate patient data; and prevent identity fraud, HIPAA breaches and incidental disclosures of protected health information (PHI).

As consolidation within healthcare continues, data management suffers and the interoperability issues become more evident; thus managing records becomes even more of a challenge. While organizations complete the conversion to electronic health records and increase information sharing through Health Information Exchanges (HIEs) and Integrated Delivery Networks, accuracy emerges as a primary concern, as overlapping and incomplete records become commonplace.

There is no doubt a UPI will lead to more informed clinical decision-making

A UPI prevents duplicate, overlapping and incomplete records from impacting continuity of care, delaying treatment, increasing the risk of medical errors, delaying billing and opening the door to fraud, all of which costs healthcare organizations millions of dollars each year. It is estimated that the average hospital has around 800,000 records, of which 8 to 12 percent are duplicates. With duplicates costing up to $50 per record pair to reconcile, this could add up costing the industry billions. UPIs could eliminate this issue.

It doesn’t stop there. UPIs benefit patients directly too. Consumer demand – and they are consumers – for access to their own health information could be satisfied, as they begin to compile health histories through apps from different health organizations, UPIs can help ensure the right person is connected with the right information. Gone would be the daunting task of assembling one’s healthcare history by relying on memory or spending an inordinate amount of time requesting records from individual providers through fax or mail and piecing together a history. Patients are demanding more ease, options and control over their care experience and providers need to start to view their patients as “customers” who can shop elsewhere, in order to improve satisfaction and maintain loyalty. This is a key step in embracing the consumerism environment that healthcare providers face today.

There is no doubt a UPI will lead to more informed clinical decision-making, allow open communication among providers, enable more integrated and coordinated care, enhance quality of care, and result in more prudent use of valuable healthcare resources. Ultimately, this approach would improve customers’ health and save lives – which we can all agree is benefit No. 1.

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I have an Aunt, who is 86 years old and provides aide services 4- 5 hours a day to a 94-year-old woman living in her neighborhood. The 94-year-old, who I will call Ethel, is what my Aunt describes as “feeble”; she walks around the apartment with a cane, needs assistance with meal preparation and other activities of daily living. However, Ethel is alert and oriented, or as my Aunt describes it “totally with it”.

Ethel has no children but is in touch with a niece, who lives a distance away but calls frequently and visits monthly. Ethel has communicated to my Aunt that she is financially secure and has not hired “a girl” because she does not really need one and prefers to pay my Aunt “to visit” instead.

Ethel’s niece, in order to give herself peace of mind, insisted that her Aunt accept an “alert pendant”. Ethel’s niece explained that it was very easy to use, and if there was a problem Ethel could hit the button and help would come. Since her niece was paying, Ethel did not want to see the niece’s money wasted so she religiously wears the alert pendant, never removing it.

If you are rolling out technology/Telehealth commit to having several modalities

One night, Ethel gets up to go to the bathroom and falls. It is 2 am, and Ethel cannot get up. Ethel crawls from her bathroom into her living room and asks “Alexa” to call both my Aunt and her niece. When my Aunt arrived and helped Ethel up from the floor she asked Ethel why did not hit the alert button around her neck. Ethel replied that the button would result in a big commotion, and she knew that “Alexa”, which Ethel ordered for herself on her computer, would not make a big deal out of the incident.

Technology and elder care still struggle with synergy, and Ethel’s story resonates with me as part of our hurdle. I had been a Home Care Nurse for over 25 years and had implemented different modalities of Telehealth with the Medicare population, the Medicaid population as well as private pay. In that time frame there, I learned few lessons that I am more than happy to share.

Lesson #1:  There is not one modality that will connect with all your elders.  We know that there is a multitude of technologies to help you achieve your health goals: For example, Apps, wearable devices, and exercise webinars. Yet for some reason, at a certain age, we seem to think one modality will work for everyone. Once you hit 75, everyone should get an “alert pendant” for example. That modality works very well for some, not for the Ethels of the world. If you are rolling out technology/Telehealth commit to having several modalities. Some people will be very receptive to Medication Dispensers, others to Interactive Monitors, while rest to Applications. Trying to oversimplify will limit adaption.

Lesson #2: People, and this includes older people, do not always do things because it is good for them. Otherwise, we would all be exercising a minimum of 30 minutes a day. Telling an older person to use a technology because it will avoid a hospitalization or will keep them healthy is not always the right motivation. It is imperative to find out what the older person’s goals are in order to impact on utilization. Some people will say “I would like a reminder for my medications”, others will say “I would like a call if I am not feeling well”. Determining the elder’s motivation will have a significant impact on utilization.

Lesson #3: No one likes to have their decision-making ability limited, and older people are particularly sensitive to that danger. Ethel’s niece was right on target that Ethel needed to be connected to avoid being stranded in an emergency. But 911 and an ER trip was clearly not Ethel’s goal. If Ethel had not had Alexa there is a high probability she would have waited for my Aunt to arrive at her designated time versus hitting the alert button. Now, alert pendants can be utilized to function just like “Alexa”, but that needs to be established in advance. Older people, like all of us, want to make sure they control their own destiny. If the technology is perceived as “reporting” and then “resulting in undesirable consequences”, the older person will not use it. Utilization will increase if the older person is assured that an alert will trigger a call to them, to discuss next steps. I had a Telehealth patient who shared that the unit would have to go if her daughter had access to her data. The patient already knew she had to lose weight but having the daughter call after each weighs in was driving the patient insane.

Lesson #4: Avoid data overload, for both you and your patients. There are amazing technologies today: sensors that alert you if someone has not opened their refrigerator or moved off the couch all day, wearable devices that will send all sorts of biometric data, interactive devices that can identify a multitude of early decompensation symptoms. The risk is not to overload the user and your own backend with data. Just because you can get the data does not mean you want it. Identify what your global goal is and choose your data points carefully. The average Telehealth user will spend 8-10 minutes using the device. That is it, so be cognizant of the time required when you are designing your program. Older people have lives too and do not want to “feel sick” by having to use a unit every day for an extended period of time. Then you have to decide what your team will focus on as a “red alert”, something that requires follow up. If you “Red Alert” everything, you will wind up responding to nothing, and the first missed crisis will result in a non-user ever after.

Designing our technology programs with the goals of the older person in mind is an important first step.

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