In this ongoing series on enabling team based care, we’re looking at how technology and human factors impact successful execution. As a framework, we’re applying principles outlined by the Institute of Medicine for team-based care:
- Shared Goals between both patient and the care team
- Clear Roles and expectations for all stakeholders
- Mutual Trust between all members of the team
- Effective Communication between all stakeholders and across all care settings
- Measurable Processes and Outcomes to track and improve performance
In a previous post, we discussed trust between all members of the team, both personally and in the use of data. We’ve also previously touched on the various settings of care and the systems necessary to communicate across them. In this post, we’ll go one level deeper and talk about the challenges as well as some examples of effective communications and trends we’re seeing.
Effectively communicating across the entire team involved in care, including the patient, is still incredibly difficult. A quick and certainly not exhaustive list of reasons why this is so difficult include regulations (e.g.,HIPAA) that mandate strict procedures for the handling of patient data, a lack of interoperabilty between competing information systems like EHRs and other data sources, and the organizational challenge of sharing data between care providers that may be competing with each other on different populations or payment contracts, all the while steering clear of regulation intended to prevent monopolies or other untoward business relationships forming among provider entities. And while many are envisioning a new breed of apps sitting on top of the data, that approach is still nascent. Simply put, the system was not designed for collaboration outside of the four walls of an entity providing care.
Value-based contracts are creating the financial imperative to overcome these barriers. With effective linkages between the various players it is much easier to coordinate patient care. This is predicated on aligned incentives between those same players to improve the quality of care and protect resources. If the primary care provider knows that their patient was recently discharged from the hospital for example, they can schedule follow-up appointments and possibly avoid a readmission or unnecessary Emergency Room visit. This requires a number of technical and workflow gaps to be jumped, linking disparate technologies and often times distinct and separate provider groups.
As providers become more sophisticated and contracts become more expansive, we are seeing an uptick in health information exchange. The Centers for Medicare & Medicaid Services (CMS) recently announced that new organizations applying to the Medicare Shared Savings Program will be required to outline an information technology strategy that dovetails with their proposed clinical and organizational approach to managing care.
Part of that information technology strategy is the exchange of clinically relevant data. Many types of Health Information Exchanges or HIEs, are in operation today. Some act as public sources of data, governed by rules to ensure data is shared and handled appropriately. These sources of data can be used in a variety of ways: for health systems analysis, public health surveillance, population health and when appropriate, to guide individual patient care. Public HIEs are active in many parts of the US, operating with a wide variety of quality and types of data and a variety of funding mechanisms including grants and other pro bono investment as well as more conventional subscription based models. Regardless of the funding source, public HIEs are often challenged to develop a return on investment strategy for their capital investment and ongoing maintenance.
While few dispute the value of the aggregation of community data, limited participation of partners (including some that may be competing for the same patients), the need for strong governance and policies around appropriate use of data and the challenges of normalizing large datasets have been a significant burden for these organizations. Private (or hybrid private/public) HIEs formed by providers (especially around new contracts or ACOs) are becoming much more common to address many of these issues by simplifying the variables: fewer organizations, leaner governance and generally smaller datasets focused around identified operational needs. We expect this trend to continue to gain traction as payers and providers engage in new models of delivery and payment.
We can all agree that data necessary to the coordination of care should be shared, but there are pitfalls that every organization has to steer clear of to ensure success. Once data starts to leave the “four walls” of your organization, who sees it, who acts on it and who’s responsible for its protection all become concerns. Data security is a key concern. A recent PricewaterhouseCoopers report on healthcare costs estimated preventative security costs average approximately $8 per patient record. That cost needs to be weighed against the costs of a major breach, which the same report pegs at $200 per record cost to deal with the fines, costs for remediation and loss of patients due to a major breach. Data security is no longer solely the realm of IT and organizations are now having to develop security frameworks to ensure that leadership is active on all fronts to ensure that data is protected.
With recent news of board members of companies like Target and Wyndham in the retail and hospitality industries respectively being pursued for liability resulting from major data breaches, a similar concern is now being voiced in healthcare. There’s no better time to tighten security. As retail and financial organizations have tightened their security, criminal organizations have stepped up their efforts on sources of healthcare data, with reports that 91% of healthcare organizations have experienced at least one data breach in the last two years from the loss or theft of patient information.
Despite the challenges, the momentum is there for sharing data, not only between members of the care team, but with the patients as well. While the general population has been reluctant to have their health information easily shared, changes to insurance underwriting due to the Affordable Care Act that make it harder to deny insurance due to preexisting conditions (although this is still evolving) and the clear value of access to a complete patient record in any setting, including the Emergency Department have made most of us somewhat more comfortable with a more portable health record.
We’re also more comfortable engaging with our providers outside of the formal office visit or phone call. The patient portal functionality in most EMRs has been mediocre at best, with workflows and usability reminiscent of early 2000’s web pages. Despite the tepid quality of most of these portals, a legacy of Meaningful Use’s requirement for the functionality regardless of its quality, many organizations are seeing the portal as another and very effective means of patient engagement. While early reports are still mixed, it’s accepted that most of us are much more comfortable doing business online. Many seniors, traditionally considered late adopters of technology, often request and can now access their Medicare accounts and Explanation of Benefits documents online in many plans. Not to mention all these young people who will be engaging the system too.
Many providers are also wrestling with how much information to share with patients, many of whom may not be as informed about how to interpret notes and labs as they relate to their overall health. Some primary care providers are seeing positive results from more sharing rather than less. The Open Notes Initiative, a technological framework for publishing data previously buried deep in the clinical record, is one such example. Patients are finding greater access to their provider’s notes to be helpful in documenting complex conditions with multiple caregivers (who may not all be on an HIE yet) or for simply gaining a better understanding of their overall health. Many providers are reporting that rather than being a burden, open notes actually strengthen the relationship between the patient and provider. Open Notes also has some high profile adherents including M.D. Anderson in Texas and integrated delivery networks like Geisinger Health System and Kaiser Permanente.
There are a number of factors in play with any data strategy. Our recommended approach is built on the bedrock of HIT: focus on workflows not functionality, work through incremental change, solve user problems and iterate. It’s an exciting time. You can embrace the challenge, resist, or wait for outside forces to tell you what to do.