Agreed, The VA is using CCDAs today for outbound communication and they started with C32s back in 2012. Looked at…
R. Hal Baker, MD is SVP and chief digital and chief information officer of WellSpan Health of York, PA.
Tell me about yourself and the health system.
WellSpan is an integrated delivery system of about 20,000 employees over five counties in south central Pennsylvania. We’re locally governed and are committed to providing affordable healthcare in the region. We were formed through strategic affiliation of independent health systems in the region. We have a large medical group practice with multiple specialties and eight hospitals.
We went from “everything but Epic” to Epic in 2017, with our Summit Health recently going on Epic last October. We are finally on a unified electronic health record across our system and enjoying that in a region that has a lot of Epic. Care Everywhere provides good inter-system interoperability.
How are you using Nuance’s DAX (Dragon Ambient Experience) and what is the business case for implementing it?
I came to WellSpan almost 26 years ago and spent my first 10 years in education with the residency program. I’m still a practicing internal medicine doctor and I’ve been using DAX since the summer. I have found that it has dramatically increased my enjoyment of practicing and also increased my ability to concentrate on the patient. I’ve always been impressed that no judge tries to be their own court stenographer and no CEO tries to take their own minutes in a board meeting. We say it’s really not a good idea to try to text and drive, and yet all of our doctors are trying to text and treat.
That mental complexity of trying to handle the documentation and the invoicing of healthcare — creating the billable note with the HCC codes and the different number of bullets for the coding requirement — simultaneously while you are trying to listen to the person who’s telling you their problem and apply a thoughtful diagnostic acumen to it — that’s a hard juggling act.
In many other areas, we have said that that’s not safe. It’s the reason in aviation for having a silent cockpit from 10,000 feet down. In healthcare, we’ve tried to do that. I did not appreciate how much I was being exhausted by that until DAX came in and I had a virtual scribe through DAX that allowed me to just converse with the patient and stop worrying about the note. It seems like it would be a small thing that might increase my efficiency, but what I found is that I am so much more able to be present with the patient and to connect with them.
For me personally, I worried that it was because I’m an administrator most of the time, you’re always thinking about other things, and you have that executive halo sitting on your shoulder that’s watching. You’re more distracted than other doctors might be. But one of our urgent care doctors was on a call discussing our efforts to reduce burnout in our providers. He gave me permission to read this in the meeting. He wrote to people:
“It hit home with what I started yesterday. I started a demo of the DAX system. I was very skeptical prior to using it, which is why I was probably chosen to demo it. I consider this a game changer. Over the past few thousand patient encounters, this is the first time I could literally sit and talk with the patient without being preoccupied. There was a clarity during the patient encounter because I was not busy typing. I think this is going to be a game changer. It’s unfortunate we have made patient encounters so incredibly busy that we are now trying to revert back to the way medicine was and should be.”
He captured what I was feeling, so I asked him if I could use that quote. But it was nice for me to see that it wasn’t just me who perceived that.
Is the result immediately available following the encounter or is there a delay as behind-the-scenes humans complete the work? Do you have to make a lot of corrections?
I started out my career writing my own notes and handwriting, which was a primitive form of encryption, but pretty effective at that. I then came into my faculty practice. I was able to dictate. I still had to listen to the patient and then regenerate the note. I then moved to Dragon because it allowed the note to be present at the end of the visit, something Dr. Jayne commented on. I really liked that and Dragon was certainly good enough. We have deployed Dragon in the exam room.
I have always dictated in front of patients because it lets them correct me and it lets them hear that I’ve listened to them. I get the notes back in four hours. We’re one of the first places to apply it to primary care. DAX was developed in orthopedics. I have gone through being a patient with a doctor doing a DAX orthopedic visit. I threw in some obnoxious things just to see what would happen and got a note back within a few minutes from the AI. It wasn’t perfect. It would have needed some editorial tweaking. But it was remarkably on target for a conversation being converted into medicalese.
What we’re seeing now is that four-hour turnaround time. I only am able to review a certain number of notes before I leave for the day and I have to do some the next day. But it’s worth it for me to be able to be fully present with the patient. Some providers really like the note to be absolutely their note and others of us are OK with somebody else writing the note as long as it got the key facts and is basically telling the same story.
I will say that the DAX notes are high quality. They’re not exactly as I would have written them, but I don’t think they are inferior, and my partners don’t think they’re inferior when they read them. But relieving me of that responsibility of mental note-taking and compiling the note in my head while I’m trying to listen and think through the problem — that’s been a win. I would say that some doctors really want the notes to be their notes and it may not be for everybody. But if you can let go of the perfection of it being your note and allow a good process to generate a note, I think it’s doing a great job. And there’s something to be said that I underappreciated about relieving the doctor of the invoicing part of medicine and just having them focus on the clinical part.
We are rolling out a pilot of 50 doctors. We absolutely know we need to make the business case. We’re going to be looking at employee and patient satisfaction, pre- and post-DAX versus DAX versus control group, people doing the old way. We are also hoping that there’s some improvement in efficiency by removing the time that you had to re-dictate the note, essentially. I only spend about 75 to 90 seconds reviewing and signing a note. I clocked myself because I knew I would have this conversation with you coming up. So it’s certainly faster than me dictating, but we are looking for that business case you talked about in your blog a week or two ago. We don’t have it yet, but we know we need it to justify a further rollout.
So your business case will mostly focus will be on patient satisfaction and recapturing the patient-physician relationship in being able to look each other in the eye instead of the physician typing?
We are looking at everything we can think of that might indicate value so that we can justify the investment in DAX. As the AI learns how to write notes from the combination of AI and scribe, the timing will get shorter over time. We’re committed to being early and we are training it. It’s much further along in orthopedics than it is in primary care. The vocabulary range in primary care is huge compared to orthopedics, in terms of what we talk about in an encounter. That’s a challenge, but we think it is already bringing in value.
I was named one of the top 10 doctors for patient satisfaction recently. I think that’s the first time I’ve been called out for that, and it was while I was using DAX. That’s an N-of-1 result, but I’m wondering if the two are related. That’s part of the reason why we are studying it.
How is the health system addressing consumerism and patient relationship management?
That’s a very dedicated part of our effort. We want to become easier to use and reduce the friction of healthcare.
Like many people, we have had a rapid rollout of video visits. We’ve been very active in online scheduling. A woman can schedule her mammogram without an order, go in and get it, get her report back that evening, and click in and look at her mammogram images on our portal. We made a commitment long ago to put in the portal that we wanted when we were patients, even if it wasn’t the portal we were always comfortable with when we were providers. We give access to adolescents up until age 18 to the parents unless there’s a special court situation, which is something a lot of people have shied away from. We gave people access to their images online. We did that in February last year, then COVID happened and we completely blew up our marketing plan for communicating it. People still found it and we got to over 40,000 images viewed per month.
We are trying to get people where they are and offer them the services so that they can interact with us with the least amount of friction. We are experimenting with Livongo with our employees. We just managed to integrate it with Epic, which was a nice cooperation between Livongo and Epic.
What were your expectations in replacing everything with Epic and what opportunities have resulted?
We had done a lot of work to put the Allscripts notes into Cerner and the Cerner notes into Allscripts to make sure all the imaging results were available in both. But the ability to coordinate through secure chat with specialists … Johns Hopkins is down the road from us and we have a partnership with them in oncology. For me to be looking at a Hopkins pathology result from eight years ago in about five clicks from the Epic record is fantastic interoperability. I dramatically underestimated how good that would be.
For us to have a patient go from one of our hospitals to one of our offices and not have to start over is part of our promise to make you feel like we know you. We have a effort we call “Know Me” to make people feel like we know who they are. For instance, the name “Levine” can be pronounced three or four ways. We have a section in our record in our Epic storyboard where we have the pronunciation so we know whether to say lah-VINE, lah-VIN, or lah-VEEN.
How do you see technology’s role in clinical and quality improvement?
This is kind of a hard concept, but our work in sepsis was so successful because we leveraged humans through technology. Rather than having a sepsis alert fired to busy ED doctors and nurses and reminding them with pop-ups that at best have about a 20% response rate, we instead fired it to a nurse who was watching over every patient in the hospital and figuring out whether that was a real problem or a false alarm. Then going to see if the team is doing everything they’re supposed to do. Not picking up the phone unless there was something that was being missed. But when they did call, the teams in the ED and the ICU quickly learned that eight out of 10 times, it was going to be a real situation.
That was a known person calling with a worry. They have actually done some research, looked at the chart, and said, “I think we’re missing sepsis here” or “I don’t see that you’ve ordered the fluids at the right rate” or “the antibiotics haven’t come down from pharmacy” and allowing us to rescue the sepsis bundle. We were able to get up to 90 to 100% compliance. With that, we are able to achieve O/E ratios — observed to expected deaths — of 0.6, 0.7 in some of our hospitals, our mortality saving over 200 lives in a year.
It was awesome when we received the Eisenberg Award for patient safety and quality for that. But I think if we tried to do it all with technology, it wouldn’t have worked. It was partly having that human voice in looking at the alerts and translating them into real or false alarm and then calling with an explanation of why I’m calling you and what you need to do in a trusted relationship. The magic part is when you put human beings with technology to create a trusted communication.
Is there an organizational effort to get rid of perceived barriers that give health systems the reputation of being impersonal, bureaucratic, and inaccessible for patients, physicians, and employees?
Absolutely. We borrowed the, “Get Rid of Stupid Stuff” from Hawaii Pacific Health. We are trying to do that. Our vision is as a trusted partner, reimagining health and reimagining healthcare and improving health. But that trusted partner thing is really important to us,. That’s what we commit to.
Our mission statement starts off with working as one. I think that is probably our biggest catch phrase — we want people to feel like we are one team, even if we are multiple offices. We’re not perfect by any means, but there’s a consistency of that exploration. I suspect that any WellSpan employee who is standing in a line in an airport hears somebody say, “That was a time when we really did a good job of working as one,” they would turn around and wonder if that was a WellSpan person, no matter where they are.
What projects will be most strategic over the next few years?
Trying to improve the efficiency of healthcare and reduce the cost. I’ve been intrigued with Livongo. Maybe we can take care of people with hypertension and only see them in the office every few years. Now that we have that integrated into Epic, it’s been really interesting to think about. With COVID, within 34 hours of the governor’s announcement, we had turned on COVID vaccine signup and had over 46,000 people signed up. You have to be ready and be able to move quickly when those kinds of things happen.
We’ve had over 100,000 people sign up for our portal in the last two months. A lot of that has been driven by COVID vaccinations. It’s up to us to retain that user who came in for one purpose and try to establish a trusted relationship that allows them to use us in an easier way online or wherever, by whatever means they want to use us with. We take care of the Plain community here, which you would probably call the Amish, so there are practices in WellSpan that have a hybrid charging station next to the hitching post. It’s all about meeting our community where they live.