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February 1, 2017 Readers Write 5 Comments

Future Health Solution
By Toby Samo, MD


Health information technology (HIT) has made significant advances over the last two decades. While adoption is not necessarily a good marker for successful EHR usage, adoption of office-based physicians with EHR has gone from about 20 percent to over 80 percent and more that 95 percent of all non-federal acute care hospitals possess certified health IT. HIT implementation has led to improvements in quality and patient safety.

However, many of the goals of increased HIT implementation have been stymied by social and technical roadblocks. A “one type fits all” approach may help reduce training and configuration costs, but there are many approaches to patient care and unique workflows between specialties and among individual users.

Most EHRs are burdened with three major legacy issues:

  1. Technology. Present EHR systems are mostly built on what would now be considered old technology. Some of the ambulatory products and small acute care products have moved onto cloud-based architecture, but most are client-server. While hosting instances of a product reduces the technical expertise needed by the client and can lead to better standardization of implementation, it does not necessarily deliver the advantages of a native, cloud-based architecture.
  2. Encounter-based. EHRs have been built on the concept that interactions with patients (or members or clients) are associated with a specific encounter. This functions well for face-to-face visits and for specific events, but is limiting where longitudinal care is required.
  3. User experience. The user experience has for the most part taken a back seat to functionality in HIT software development. A quick view of most HIT systems shows the interface to be cluttered and does not draw the user’s attention to the areas that need the most attention. Most users access only a small percentage of the functionality that is present within the system, but vendors continue to add functionality rather than clean up the interface.

Platforms have revolutionized the way business is conducted in many industries. Numerous examples have made household names out of companies like Airbnb, Uber, Facebook, YouTube, Amazon and many more. A platform is not just a technology, but also “a new business model that uses technology to connect people, organization, and resources in an interactive ecosystem.”

There is a need for a HIT platform that would support the multitude of components necessary to move the delivery of HIT into the next generation. The future health solution needs to use contemporary technology that will have the flexibility to adapt to ever-changing requirements and use cases of modern healthcare. Some of the characteristics of the future health solution are:

  • Open. One of the biggest complaints of users and regulators is the closed nature of many HIT systems. The future health solution needs to be built as a platform that is able to share and access not only data, but also workflows and functionality through APIs
  • Apps and modules. A modular structure will enable components to be reused in different workflows and encourage innovation and specialization.
  • True, cloud-based architecture. Cloud computing delivers high performance, scalability, and accessibility. Upfront costs are reduced or eliminated and minimizes the technical resources needed by the client. Management, administration, and upgrading of solutions can be centralized and standardized.
  • Multi-platform. Users expect access to workflows on their smartphones and tablets. Any solution must develop primary workflows for the mobile worker and ensure that the user interface supports these devices
  • Scalable (up and down). To meet the needs of small and large organizations, the future health solutin will need to scale to accommodate changes in client volumes.
  • Analytics, reporting, and big data. HIT systems have collected massive amount of data. The challenge is not just mining that data, but presenting the information in a way that can be quickly absorbed by the individual user.
  • Searchable at the point of use. All the data that is being collected needs to be readily accessible. Using universal search capabilities and the ability to filter and sort on the fly will facilitate the easy access to information at the point of care.
  • Privacy and security. The core platform will need to be primarily responsible for the security and privacy of the data. The other modules built on the platform will need to comply to the platform security and privacy practices, but will not need to primarily manage these issues.
  • Interoperable. Need to adopt all present and future (FHIR) standards of data sharing. The open nature of the platform will facilitate access to data.
  • Internationalization and localization. Internationalization ensures that the system is structured in such a way that supports different languages, keyboards, alphabets, and data entry requirements. Localization uses these technical underpinnings to ensure that the cultural and scientific regional differences are addressed to help with implementation and adoption.
  • Workflow engine. Best practices can change and can be affected by national and regional differences. An easy-to-use workflow engine will be a necessity to help make changes to the workflow as needed by the clients.
  • Task management. Every user has tasks that need to be identified, prioritized, and addressed. Therefore, a task management tool that extends beyond a single module or workflow will be needed.
  • Clinical decision support. Increasingly sophisticated decision support needs to be supported, including CDS, artificial intelligence, and diagnostic decision support. These capabilities need to be embraced by the platform, allowing external decision support engines to interface easily with the other modules.
  • Adaptable on the fly by the end user. Allowing the end user with proper security to make changes to templates and workflows would help improve adoption.
  • User experience. Probably the most significant barrier to adoption of HIT is the user experience. Other industries are way ahead of healthcare in the adoption of clean, easy-to-use interfaces. It is vital that a team of user experience experts be integrally involved in the development process. All user-facing interactions, screens, and workflows need to be evaluated by user experience experts who can recommend innovative ways the user interacts with the system and how information is displayed.

The HIT industry has hit a wall that is preventing it from developing innovative products that use the newest technology and have an exemplary user experience. A new platform has the potential to support a robust, flexible, and innovative series of products that can adapt to meet the needs of the various healthcare markets globally. Such a project would have to build slowly over time, as does any disruptive technology. The legacy systems and other HIT systems that exist do not have to be excluded, but rather can be integrated into this new platform.

Identifying technology that, at its core, has the privacy, security, data management, and open structure could lead to the next generation of healthcare management systems. While some of these characteristics are obvious to developers and users alike, it is the sum of the parts that is important. Integrating most if not all of these characteristics into a single model is what can lead to enhancing the value of HIT and the delivery of care.

Toby Samo, MD is chief medical officer of Excelicare of Raleigh, NC.

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Currently there are "5 comments" on this Article:

  1. Excellent! The industry MUST move from legacy to contemporary. May the transition with closed EHR products begin soon.

  2. Given the billions it took to get where we are today, I hope we don’t waste more billions making Doctors the highest paid data entry clerks in the world. Let’s focus on the patients and not the EHR. If we define technology as simply, “doing more with less”. Applying real technology to health care is the way to go and those won’t require wasting billions because they’ll have a real ROI. Some of this list does seem to have a real ROI, unfortunately inter-operability isn’t one of them.

    Also, the push for socialism which goes by many names “value-based care”, “longitudinal care”, “population health” simply won’t work well. Like Gary Kasparov said “The failures of capitalism are still better than the successes of socialism.” I know many vendors are trying to position themselves to profit from the rise of socialism in health care. I’d wish they would instead focus on building, marketing, and providing real technology to the health care industry.

  3. PM_From_Haities, your rant about socialism is inappropriate and out of place.

    The bromide to focus on the patients would be great if you were the former head of the American Medical Association, pushing an anti-technology agenda. Unfortunately for you this is HISTalk; I would suggest you look up what the “IT” stands for.

    There’s no going back to the past for healthcare. My job changed back in the 90’s when the internet became available to my clients, such that they could question my advice and information. I learned to adapt and thrive. Successful clinicians will do the same.

    The mistake some clinicians made was to equate Obamacare, or EHRs, with all the other changes going on in healthcare. Most important is the easy availability of information through the internet. Second was that healthcare had fallen far behind other industrial sectors in modernizing.

    As for you swipes against interoperability, pop. health and the others, no. Just no. Bang that drum if you want to, it’s your reputation. You’ll look about as smart as railing against ICD-10, “This dang computer thing”, or telling kids to get off your lawn.

  4. Brian Too – I’m perfectly okay if you feel better by making ad hominem attacks against me. I can take it, but realize they are just that attacks against me not my position that socialism doesn’t work and that the move to population health, value-based, and other moves away from fee-for-service is just that socialism.

    First, an EHR may be technology with respect to billing as it’s “doing more with less”, but for clinical people in almost every case EHRs are about doing more with more which isn’t technology. Feel free to brand me as being opposed to “snake oil” EHR solutions. Health care is having what I call it’s “robot moment” in reference to the manufacturing industry’s over zealous use of robots only to find they weren’t really making things more efficient (see the famous book The Goal).

    Dr. Google did a phenomenal job of organizing the world’s information and it dramatically impacted real doctors. The question is did health care really fall behind other industries and what does it mean to “fall behind”? I’d argue given that health care costs are rising faster than inflation and that the cost of health care is dramatically up that what ever is happening isn’t working. It has only fallen behind in that costs are out of control. Socialism has a tendency towards that end because it has no pricing function.

    As for ICD-10, I personally added support for ICD-10 to a system back in 2005 so that it would be ready thinking health care wouldn’t wait another decade. Health care is slow to implement as it should be for patient safety. The problem with health care is the outrageous increases in cost and lack of pricing transparency. Population health doesn’t really address either.

    Here is what I propose for population health, it should be a federal oversight group that works on reducing insurance costs through population health initiatives. It should be setup in such a way that doctors have a real career path (as they’re the only profession that doesn’t make more with experience). It should sit completely outside of today’s health care ecosystem and serve as a check-and-balance in much the same way as congress does to the executive branch. It should focus on real science-based policy changes. For example, the AMA position on high fructose corn syrup is deplorable (http://www.cbsnews.com/news/reprieve-for-high-fructose-corn-syrup/). If the science and research isn’t sufficient, the AMA should have been advocating for the research to be done rather than be in pocket of high fructose corn syrup sellers. Though correlation does not equal causation, the fact obesity rates are heavily correlated with high fructose corn syrup consumption should not and cannot be ignored. These new organization should be tasked with “making america healthy again” and setting up a real health care system not one that operates solely as an “illness and disease system”. The problem is our current system needs to stay in some effect as people do get sick and do need treatment. Nothing like this is being proposed for population health today, it is almost all focused on moving the current system to a socialist model.

  5. One clarification on this. When I refer to EHRs I’m referring to a generalization of the entire industry and not Excelicare’s EHR (the poster’s company). I’ve never used nor really know anything about Excelicare’s EHR. I have, however, observed the work of Cliff Meltzer and he did a wonderful job when I was aware of his work at Allscripts. It’s always been surprising to me that his tenure was so short (only a few years at Allscripts) so I’m not surprised that he moved on to more prosperous job as the CEO of Excelicare. People like Cliff will move the needle on the improvements necessary to push EHR technology forward.

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