The recent proliferation of connected devices, sensors, and other equipment has made it almost too easy for healthcare organizations to acquire data. The potential benefits are evident: mining this data to make more informed decisions about their internal operations and patient care.
The problem however is that just having access to data does not in itself produce results, either because it is not reliable or not easily understood. Healthcare institutions need to focus on the fundamentals of data analysis to uncover the relevant nuggets of insights which help drive decision-making.
Bad data muddles up analytics, and bad presentation of data can put the focus on the wrong things or miss the mark altogether – it’s essential that the data be trusted and actionable. So how can healthcare facilities identify more meaningful insights that ultimately improve patient care? Here are some things to keep in mind:
Make data available in real time
The emergence of real-time data sources is having a dramatic impact across all industries. Data analysis no longer has to be a retrospective waiting game. It’s now enabling organizations to ask, “What’s going on right now, and what can we do about it?”
Take for example the challenge of improving patient satisfaction scores. Hospitals have a pretty good idea of what contributes to a positive patient experience: short wait times, meaningful interaction with caregivers, and effective communication with patients and family.
But a report on essential metrics like on-time start percentage and patient/provider contact time that arrives even a day later isn’t very helpful. It’s hard after the fact for caregivers and managers to link these stats to specific events and thus gain insight on how to do better.
If the information is delivered in real-time by leveraging technologies such as real-time location systems (RTLS), caregivers can respond immediately to a patient who has been waiting too long and managers can better anticipate and eliminate bottlenecks in the overall patient flow. Data created by an automated RTLS can be much more accurate and timely than that entered in manually, often well after the fact and also much less accurately.
Present data in a simple, meaningful way
Simple, visual dashboards are essential to make the data actionable. They enable staff to more easily monitor and understand a patient’s care process in a manner that is intuitive and doesn’t require data analysis expertise, while quickly identifying pain points of procedural inefficiencies to get ahead of a problem before it occurs.
As an example, take a look at hand hygiene procedures in a typical hospital. Healthcare-Associated Infections (HAIs) cost organizations over $35 billion annually and are a pervasive threat to patient safety. Using real-time monitoring and dashboards, however, hospitals can show staff members how they are doing individually, and show managers how the unit or hospital is doing overall – all through visual analytics. This allows for immediate action or longer term interventions such as further education or mentoring.
Dashboards take real-time information about patients, staff and assets, and provide faster insight into how to improve the patient experience – whether by resolving issues that impact wait time or seeing what’s causing reduced staff contact time. Doctors and nurses can even access dashboards on-the-go on a tablet or wall-mounted display to gain real-time visibility into what’s happening in the OR, waiting rooms or post op rooms to make sure everything is running smoothly.
Today, dashboards loaded with predictive analytics are becoming a reality as historical data uncovers trends. Looking at the facility’s records, organizations can better predict trends in the coming hours, weeks and months to make more informed decisions, such as using previous data on infusion pump deployments to identify how the devices should be distributed and when more will need to be ordered or rented.
Bring on a data expert
There’s a movement to bring self-service analytics to the masses. Business intelligence (BI) and data visualization tools like Tableau, Qlik, Microsoft and SAP are paving the way for non-technical individuals to analyze and make sense of data. But the simplicity of these solutions for users masks great sophistication on the back end both in terms of managing the data and building dashboards that non-data experts can rely on to make strategic decisions.
Organizations need to be able to differentiate between “good” and “bad” data if they hope to avoid confusing or non-correlated results. An experienced analytics team knows that data integrity is the key to success.
Healthcare institutions should either look into third-party vendors to handle and manage data analysis, or find a data expert to bring in-house. There are increasingly more BI teams emerging within hospitals as of late, due to the value deep data analytics provides. As the availability and applications for analytics solutions continues to grow, it’s safe to say this trend will only intensify. Often these in-house teams will partner with vendor teams who are experts in their solutions as a starting point, then take over day-to-day operation of the BI systems once launched.
Spot and breakdown data silos
When implementing new technologies, it’s also important to consider data silos; particularly how to avoid creating new silos and how to eliminate old ones.
Data silos are repositories of data that are isolated from other parts of the organization. Healthcare groups should use all of the data that is available to them to drive more informed decisions and ultimately help improve patient care.
For instance, being able to combine RTLS data with clinical performance data provides caregivers with a more complete picture of the patient journey. Ensuring that the RTLS system is integrated to the clinical system and that a common “key” exists is essential to being able to blend and analyze this type of data.
The good news is that data silos are being broken down more and more, and larger organizations are leading the charge with tools like Tableau, Qlik and SAP. By taking advantage of the connectors in BI solutions, organizations can easily combine SQL, Oracle, Excel data and more to gain holistic discoveries.
The amount of data flooding through hospitals today is unprecedented. But that doesn’t mean it’s being used effectively. Organizations need to develop a strategy that delivers on the basics of data analysis — understanding the data at hand, ensuring its quality, finding the relevant bits to combine and analyze, and presenting it in a way that’s easy to consume. It’s an approach that’s already delivering results in better care and higher efficiency in forward thinking healthcare organizations.
Image: Stuart Miles, FreeDigitalPhotos.net
Dr. Michael Miller, director of research informatics, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, discusses how as a research informaticist, he uses data for clinical care as well as research. Dr. Miller is interested in learning how to use information entered into EHRs for the maximum benefit […]
In celebration of Data Privacy Day, taking place each year on January 28th, members of the HIMSS Privacy and Security Committee talk about ways to help protect patient privacy. In part 1 of the series, Meredith Phillips, Chief Information Privacy and Security Officer for Henry Ford Health System discusses several common scenarios involving breaches […]
Jonathan Bush, the forever loquacious, occasionally foul-mouthed and mostly unscripted CEO of cloud EHR company athenahealth, got the audience cracking up at the annual Stanford Medicine X conference in Palo Alto, California when he took the stage, declaring:
“Shit, I have nothing visceral or profound for you.”
He was referring to the unenviable position of having to follow the moving presentations of patients and artists that preceded his keynote on Saturday. This handicap notwithstanding, Bush managed to inform and entertain the audience with his tech-enabled vision for healthcare.
Later, in an interview with MedCity News, he talked about the future of information exchange and electronic health records. Here’s a slightly edited version of the conversation.
MedCity: If you were a hospital CIO, what would you demand of EHR vendors.
Bush: I don’t believe there should be EHR vendors. I believe records should be national networks like cable companies. I think if I were a CIO, I would sign on to a national network like athenahealth and I would not attempt to build my own biosphere of clinical information.
I would be humble enough to know that most of the time patients I receive have charts before they arrive [at my hospital] and I would like to be connected to wherever they came from. Most of the time patients I see will go somewhere else and would benefit from whatever information I added to the pile.
This is hard for CIOs because CIOs have gone from the back room to the board room over the past 20 years partly because of giant capital expenditures to build largely isolated offline electronic health records. And I agree that an electronic health record is better than a paper health record, but this is 2016. An electronic health record is not remotely as good as a national electronic record network.
MedCity: But given that Epic has a large market penetration, how do you contend with that? If you were a hospital CIO and you had Epic, what would you ask of them?
Bush: I think I would ask them to connect and that’s starting to happen. For years and years hospital CIOs were asking Epic not to connect because they thought, ‘We will buy up all the doctors and they won’t be able to escape and all their referrals would come to us because the only way you can refer anything is through Epic and the only thing on this copy of Epic is us. So we’ll get of our specialists, and we’ll get all the referrals.’
What hospitals found is that doctors would verbally tell the patient where to go and the patient would go wherever they want. And they also found that a lot of patients were being aggregated not by the primary care practices that they bought but new purveyors of primary care like retail clinics and urgent cares. The hospitals needed to connect to those because they wanted those referrals. So they suddenly went from how closed can you make us to how open can you make us.
What we’re doing now is that we are connecting to most of the Epic hospitals in the country and that’s been something that Epic has just allowed us to do in the last couple of months.
MedCity: So they are opening up…
Bush: They are opening up and I am cautiously optimistic. And we are providing services on top of that. So even if the hospitals is doing its record keeping on Epic, as long as we can get access to the clinical record data, then we can do population health, we can do patient outreach … and theoretically someday update the record at Epic.
I believe what will happen because Epic is largely run by good people and their customers are largely good people, is that the pressure has built to a degree that not only will they let us in to see the record but eventually start writing to it.
I don’t think doctors will hold EHRs in their hands in five years. I think they’ll be on Epocrates (used by docs to look up drug info) or some other app and they’ll call those records like you pull down a story on Audible or you pull down a movie to your device. So you stream it and then it goes back. You don’t keep it.
MedCity: Tell me what you can do with Epic today.
Bush: What they are letting us do is pull CCDs out of the Epic database. CCDs are continuity of care documents – it’s a government mandated, almost like a pdf. It’s like an electronic fax. Judy (Faulkner, CEO of Epic) has built a nonprofit that has a patient key that’s lets you figure out whether my John Smith is this same John Smith in Epic and match, and so we have built a matching service off of that.
MedCity: How does that help the patient?
Bush: So if you check into a cardiology practice here in town on athenaNet, we can quietly search all the Epic installations within 50 miles to see whether you have been in any of those facilities and then say ‘Ah I found you. This person has been to this hospital. This person has been to this hospital. Here’s what’s in the charts.’
MedCity: And how did that conversation come about with Epic?
Bush: Well for seven years, they told us to pound sand and (then) a series of events built. We’ve been getting more and more of the retail clinics, and the hospitals that are on Epic have been more and more needy of those referrals.
The other is that Epic lost the Department of Defense contract for doing the whole military after winning all of the feature function bake-offs because of their inability to suck in the charts of the soldiers from wherever they were.
And the third was the House Energy and Commerce committee started to subpoena Epic executives charging Epic of stealing federal dollars under the Meaningful Use Act (because their systems didn’t encourage data sharing). Epic didn’t steal under the Meaningful Use Act; they didn’t attest to the Meaningful Use Act. Epic’s customers did and it’s Epic’s customers responsibility.
And Meaningful Use doesn’t really require you to be that interoperable. So Epic did the technical, legal thing which is their only obligation, but lot of Congressmen and Senators were pissed because they thought they were getting something else.
MedCity: What’s the roadblock to interoperability?
Bush: I think the primary problem is the business model. There isn’t a way to profit from doing the extra mile that you would need to do to have integrated information. So the elaborate kind of final solution talk that you hear at all these conferences is to move everybody to full-risk contracts where suddenly you don’t want to do duplicate tests because that’s lost profit to you. That’s certainly true.
But there’s lot of simple things that could happen.
If a specialist gets a patient electronically from a primary care doctor, and actually you do a time-in-motion study on the work that that specialist’s staff has to do to get that person’s chart prepared and ready for the specialist to see, it’s like $45. What if the specialist could give the primary care doctor 20 blank fields and say, ‘If you fill these in for me, I will pay you $20 for a patient, and by the way here’s my calendar and you can book the patient?’
That’s illegal, but it doesn’t have to be illegal.
There’s a lot of things that are shy of turning a doctor into an insurance company. There are venture-backed companies that are starting up and growing quickly that are essentially buying primary care practices and trying to disrupt the insurance company. They are interesting and ambitious and they are going to be game changers.
But that’s a very complicated, risky, expensive way to get to clinical information integration. Just making it legal to pay someone for integrated clinical information would be a huge thing. And the number of people that are ready to take on the financial risk of being an insurance company is a much smaller number than the number of people that would be glad to figure out a way to pay for electronic information to leave their office in exchange for 20 bucks.
MedCity: You can now tap into Epic’s databases and eventually feel that you can even write on top of their medical records. What about the cybersecurity issues that naturally will arise?
Ten percent of all ambulatory care happens through athenaNet, but if we can get at all of Epic’s and Cerner’s databases we’re talking about most of medicine is available through athenaNet. That could change the pace of innovation not just for digital health but for providing healthcare, for providers.
Certainly we can afford better information security people than most community hospitals can (a reference to the California community hospital that got hacked using ransomware and which had to pay up to get their systems back online). The flip side of course is that if you hack us, you get a lot more access to data than a community hospital.
But that’s like saying if you build a super highway, won’t cars be going faster?Won’t therefore somebody be killed. Yes. But we all know that the benefits dramatically outstrip the risks.
The key is for athenahealth to be super vigilant to just over check ourselves so that we don’t slow down this inevitable movement to the cloud with some chilling, embarrassing event.
Photo: Stanford Medicine X
The Pop Health Forum, a conference put on by the Healthcare Information and Management Systems Society (HIMSS) in Chicago this week, was as much about patient engagement as it was about population health.
This makes sense, because it’s difficult to manage populations without reaching out — engaging — members of those populations.
Jeffrey Springer, a vice president at Princeton, New Jersey-based health IT vendor and consulting firm CitiusTech, said that getting to population health means checking all nine squares on a 3-by-3 matrix. The X axis covers acute, ambulatory and whole-patient care, while the Y axis is about execution on clinical, financial and operational metrics.
Patient engagement falls under all three care rows and at least two of the execution columns. Yes, financial performance has elements of patient engagement.
At University of Chicago Medicine, about nine miles south of the downtown conference site, the annual operating plan for fiscal year 2017 has patient experience as one of the five pillars of the plan, along with people, quality/safety, finance and long-term strategic positioning. Debra Albert, chief nursing officer and vice president of patient care services at U. of C. showed this slide during her presentation:
(Click here for a larger version.)
“We’re really trying to drive a consistent patient experience across all of our platforms [of care],” Albert said.
In fact, patient experience is part of what Albert called the “value-based core” of the academic health system’s goals for 2017. In her view, value equals quality — including the patient experience, proper resource utilization and clinical outcomes — divided by cost.
University of Chicago Medicine hasn’t reached true value-based care delivery yet. However, the goal is so important to the organization that the chief medical officer is in charge of implementing the core of enhancing collaboration, promoting telemedicine and selling faculty members on the concept of value-based healthcare, Albert explained.
Indeed, clinicians are empowered as much as the health system aspires to empower patients.
About three years ago, U. of C. instituted what Chief Experience and Innovation Officer Sue Murphy called “leader rounding.” At the time, rounding on inpatient wards and in the emergency department was paper-based. “We had no way of knowing what was going on,” Murphy said.
The organization standardized inpatient and ED nurse rounding on iPads, consulting unit leaders and rank-and-file staff on redesigning rounding processes. U. of C. created a system of alerts and accountability, analyzing rounding trends and rewarding nurses for good work.
Initially, Murphy and other executives didn’t realize that every nurse leader had a different comfort level with the iPads and with technology in general. Patients also had varying reactions to the presence of a tablet with each nurse who stopped in the room. “We came up with some keywords to say to patients,” Murphy said, to help reassure those who saw the iPad as an intrusion on the patient-clinician relationship.
Individual nursing leaders also have been given autonomy to make process improvements within their departments and wards. “We strongly believe that the leader of a unit is kind of the mayor of that unit,” Murphy said.
According to Press Ganey surveys of University of Chicago Medicine, 81.9 percent of inpatients in August 2015 reported that a nurse manager checked in on them daily. That number rose to 93.8 percent in July 2016.
Overall hospital ratings, as reported to the Centers for Medicare and Medicaid Services, jumped from about 60 percent in 2011 to nearly 75 percent in the reporting period that ended in the second quarter of 2016. There was a sharp increase in 2013, the year the health system started rethinking nurse rounding.
“Those many patients were touched,” Murphy said, gesturing to data on a PowerPoint slide. “They were touched by a kind word, by technology, by a caring nurse.”
Here’s the tricky thing about patient engagement: It means something different to each patient. Further, when it comes to designing for patients, it’s important to remember the mantra Apple’s Steve Jobs lived by.
“Patients, I think, define their own engagement,” Boissy, said. “Engaged in technology doesn’t equal engaged patients.”
Boissy knows this on a personal level, not just as a practicing neurologist and physician executive at a prestigious institution. She said that her stepfather died of leukemia about two weeks ago.
“Was he an engaged patient? He never logged on to his portal. He never cared what his labs were and he never got involved in his health on social media,” Boissy said. But she did on his behalf, so, by the measure of his family, he was engaged.
It’s also important to understand that some patients simply don’t want to be engaged, or they care more about old-fashioned notions such as reducing waiting than they do about technology.
“What are we doing to fix patient delays?” Boissy asked. She said that reducing waiting — for appointments, in the office, for results and diagnoses — is one of the most innovative things healthcare can do today, even though it’s addressing an age-old problem.
“I would submit to you that goal No. 1 has to be access,” Boissy said. Patients can’t be engaged if they can’t even get to the health system. She noted that Cleveland Clinic went to same-day ambulatory appointments about six years ago.
And she didn’t just mean access to care. Boissy said her definition includes access to information and people — convenient access. Not every attempt to reach out to people makes interaction convenient, so the Clinic also is working on integrating and simplifying its electronic touch points with patients.
“I just learned that the Cleveland Clinic has 22 apps, many of which have not been updated in years. That, to me, is not a seamless, cohesive digital platform,” Boissy said. This hodgepodge increases inconvenience and stress for patients and does not exactly help the brand, she noted.
“Interactive TVs are just another thing we can throw at people,” Boissy added. They need to be connected to the electronic health record so patients can see specifics about their own health on in-room screens.
Boissy, who chairs the Cleveland Clinic’s annual Patient Experience Summit, spoke of the importance of empathic design for patients. “If you were curious about their journey, you would design differently for them,” she said.
She then shared a quote from the late Steve Jobs: “You’ve got to start with the customer experience and work back toward the technology, not the other way around.”
This led Boissy to question the “patient engagement” appellation. “Maybe we need to change the name of patient engagement,” she mused. “People engagement and relationship engagement are things I think about all the time.”
Indeed, it’s not just patients who crave satisfying experiences with the healthcare system. Clinician and caregiver burnout are rampant, as evidenced by the estimated 400 physicians who committed suicide in the U.S. last year, Boissy said.
Photo: Neil Versel/MedCity News
Another week, another healthcare communications platform — but this one might be different from most of the others.
Monday, McKesson Health Solutions, a Newton, Massachusetts-based division of McKesson Corp., introduced the McKesson Intelligence Hub, an interoperability system that focuses on reimbursement and payment.
It’s distinct from the company’s RelayHealth, which helps healthcare organizations share clinical data. It’s not like newly funded startup Klara, the latest in a line of clinical messaging platforms, and it’s unlike Salesforce Health Cloud, NantHealth and SAP Connected Health, which can support genomics. Those are all made for providers, whereas the McKesson Intelligence Hub is targeting the payer market, according to Amy Larsson, vice president of clinical claims management at McKesson Health Solutions.
Instead, the McKesson Intelligence Hub connects various reimbursement-related technologies from McKesson and other vendors, based on open standards such as Health Level Seven International’s Fast Healthcare Interoperability Resources (FHIR). The cloud-based hub is backed by identity/access management as well as by management of application programming interfaces to third-party applications.
“This is to support value-based care,” explained Larsson, a registered nurse. “This is a fundamental component.”
The system connects payer networks to providers and payment systems, breaking down data silos and helping to streamline authorization, claims submission and payments. “You can extract data from EMRs to generate authorizations without phone calls,” Larsson said.
“To make [value-based reimbursement] work, we must achieve interoperability at scale—and that means across payer, provider and vendor lines,” Larsson wrote in a white paper supplied to MedCity News. “We must unlock these silos and shift to true healthcare interoperability if we are ever to realize the long-sought- after goals of higher-quality care delivery; and better outcomes for patients in an efficient, cost-effective healthcare system.”
She said she has been fighting to knock down data silos for 25 years. Only now is she realizing her dream.
If the technology works properly, it should pay for itself, Larsson said. “As you create these interoperable platforms, you naturally take waste out of the system,” she said.
McKesson Health Solutions is a unit of McKesson Technology Solutions, which the parent company is spinning off into a new, yet-unnamed venture with Change Healthcare Holdings of Nashville, Tennessee. Timing of that deal is unclear now that the U.S. Department of Justice has asked McKesson and Change Healthcare for more information about the transaction as part of a routine antitrust review, but the plan is for the Intellegence Hub to become part of the new company.
How many drinks do you consume per week? How frequently do you exercise? How’s your diet?
For most people, this line of health behavior questioning can be the most uncomfortable part of a visit to the doctor’s office, possibly with the exception of those parts involving rubber gloves. If you’re like most people, you get a bit nervous, do some fuzzy math, and maybe flat out lie.
This is not unusual.
People lie to their doctors, often. In medical school, we learned that it’s usually safe to double that number of drinks per week the patient reports. The same thing goes for cigarettes and illicit drugs. A glass of wine with dinner? Try a bottle. Only on the weekends? It’s probably a daily habit.
With all this misinformation, what’s a doctor to do? Some relief may come from a new generation of wearables and smart devices, which are helping us better understand people’s actual health behaviors and what we can do to improve them.
Finding a source of truth
The misinformation may not be due to deliberate duplicity. It turns out that people are terrible at estimating what they’ve done. The American Journal of Epidemiology published data that showed, on average, people unintentionally under-report their total caloric consumption by nearly one third.
This is problematic for a number of reasons. Inaccurate reporting can impact the doctor’s ability to make the right diagnosis or provide necessary counseling. It can have a negative impact on the patient-physician relationship. It can even be dangerous for the patient. I had several experiences in residency where patients went into withdrawal a day or two into their hospital stay because they lied about their alcohol consumption or drug use.
Relying on people’s recall alone to gather accurate information about their health habits is clearly a flawed method. What if, instead, there was a source of truth for this information? Some way for behavioral data to be easily collected, stored, and shared with your doctor, with less awkwardness and fewer lies. Could wearables and smart devices be this source of truth?
Friends don’t let friends behave badly
One of the biggest challenges when trying to change behavior — whether it’s your own, a friend’s, or a patient’s — is maintaining motivation over time. You may tell yourself that you are going to get more exercise or eat less sugar, but if nobody is there to sloth-shame you into going to the gym or slap that cookie out of your hand, chances are you will revert back to baseline. The motivation to stick with lifestyle changes wanes quickly, which is why fitness resolutions for the New Year rarely last past February.
Enter accountability. If you’ve publicly avowed to give up dessert, you’re going to hear about it when you dive into that cake at a family dinner. If you’ve found a gym buddy, you’re going to think twice before hitting snooze and skipping your morning workout. There is a tremendous amount of research around the impact accountability has on successful health outcomes. This is one of the reasons why Weight Watchers makes accountability a core pillar of their program, and why studies have found that programs like these are the most likely to lead to lead to long-term success.
As a result, a number of startups have emerged that use accountability and wearables to promote health behavior change. Omada Health helps people at risk for chronic disease with an online digital health program that includes a health coach, online group support, and smart technology to collect data. The app Pact keeps people accountable to their health goals with financial incentives — if you don’t meet a health goal, such as logging exercise three times per week, you must pay other Pact members; if you meet the goal, others pay you. There are even tools that focus on self-accountability, like Pavlok, a wearable device that delivers a mild zap to train your brain to dislike bad habits and prefer good ones.
You can lie to your wearable, but it’s a bit more difficult…
While these forms of social accountability are great, they don’t address one big issue — that people tend to underestimate their overall consumption and are generally bad at reporting their behaviors. That salad you ate as part of a healthy eating kick may have way more calories than you thought (like the McDonald’s kale salad that has more calories, fat, and sodium than a Double Big Mac). And that crazy intense workout you just crushed probably burned far fewer calories than you think it did (one study found that participants were “inept” at judging the intensity of their workouts).
Unfortunately, good intentions only get you so far. Making meaningful lifestyle changes not only hinges on social accountability, but also on a clear-eyed understanding of your own behaviors. This is another place where wearables and smart devices can come into play. By collecting data for you, these devices can help create an accurate picture of your lifestyle, highlight problem areas, and provide the data you need to make impactful changes.
Fitness trackers are a great first step, and we are now seeing a new generation of smart devices emerge to serve as sources of truth for other health behaviors. Smart cups, forks, and plates can automatically track and log what and how much you consume, arming people (and their doctors) with the data that they need to stay accountable, change behaviors, and get healthy.
Of course wearables and smart devices are not yet the perfect accountability partners. It is still possible to lie, even to them. You can strap your activity tracker on your dog, log a salad while you’re waiting for your cheeseburger, or “forget” to use your smart cup for that margarita.
But it doesn’t mean they don’t have value. After all, you can lie to your partner, friend, or Weight Watchers group, but most people who are seeking greater accountability probably realize that is counterproductive. Even if they don’t, wearables at least make lying a bit more difficult. You likely won’t spend hours falsifying your Fitbit data before your annual physical, so that data may result in some advice from your doctor around how much exercise you need to reduce your risk for a whole host of preventable chronic diseases.
At some point, lying takes more energy than simply letting the truth be known and embracing the consequences, which just might result in getting healthier.
Photo: Flickr user Heidi Forbes Öste