Brainstorming for Better Healthcare: AMDIS Style

You Have 10 Minutes … Two dozen CMIOs, several challenges, lots of big ideas. GO! Participants in the brainstorming breakout session at the AMDIS Physician-Computer Connection Symposium answered questions about clinical documentation, medication reconciliation and using healthcare IT more effectively

Facilitating the session were:

• Lyle Berkowitz, MD, FHIMSS, director of the Szollosi Healthcare Innovation Program, Chicago
• William F. Bria, MD, AMDIS president and CMIO at Shriners Hospital for Children, Tampa, Fla.
• Howard Landa, MD, CMIO/Pediatric Urology at Hawaii Permanente Medical Group, Honolulu
• James E. Levin, MD, PhD, CMIO of Children’s Hospital of Pittsburgh of UPMC

The idea of this session was to present various scenarios and constraints for physician leaders and ask them to come up with innovative ways to solve the problems posed. Some of these ideas will never be associated with the phrase “you heard it here first,” but others will likely resonate as healthcare IT evolves. “Are these ideas going to go into production? Of course not, but they may help you think about new things,” says Berkowitz.  

Scribes in 2015

It’s 2015 and there is now 100 percent EMR adoption nationwide, but the government has banned physicians from touching computers. Assume scribes are now mandatory for all doctors. How would you use scribes in your practice?

• Scribes as physician partners. Each physician would have one or more scribes as a partner in EMR review, documentation and ordering. The diversity of tasks and data retrieval and entry requires a degree of specificity, so scribes would have a moderate level of healthcare education.
• Scribes as patient partners. The scribe would be attached to the patient rather than a specific doctor, and would be part of the patient’s experience before, during and after the encounter. During the physician encounter, a scribe would record all relevant information, write prescriptions and instructions for a patient. Post visitation, the scribe would follow up with educational or clinical calls, texts or secure messages.
• Scribes as extenders. In the ambulatory space, the scribe could be an extended function of the medical assistant and would get history, take vital signs and stay with the patient during the physician visit. On the inpatient side, a scribe would be more of a resident assistant, doing a lot of the non-medical administrative tasks while at the same time acting as scribe for the physician.
• Scribes as non-humans. Scribes could be computers or robots with speech-recognition abilities that would record the entire encounter.

Documentation in 2020

It’s 2020. The U.S. healthcare system pays all doctors an annual lump sum to take care of all of their patients. Assuming documentation is now used for clinical purposes only (e.g., not for reimbursement or liability), how would your documentation be different?

• It would aggregate information from more sources. We’d want to include as many clinical information resources as possible: the patient, pharmacy, other providers, the patient’s family. The computer would do the cleanup, sort and align information in the note.  It would be social media-based. The format of the note could be a social media platform for an ongoing conversation, and not just clinicians or medical personnel could enter information. We’d make sure the patient has input.
• It wouldn’t be static. The note wouldn’t be limited to the encounter: Over a period of days, multiple people could contribute to the discussion, moving away from a static note. The note would show what you need to know at that time, providing you with only prior information that is relevant for today’s visit. Problems, labs, meds and other pieces of data would be linked to any background information for details if needed. For example, this extra data can be accessed by hovering over a node in the EMR to expand the information in it.
• It would live online. The encounter doesn’t have to happen at the office, and patients can review their visit at home, on video. Physicians could create the note using the Second Life model—patients and physicians would have avatars, and engage with other avatars for second opinions and other patients’ experiences with their condition.

Accurate PTA medication information

Getting accurate Prior To Admission (PTA) medication information is problematic in many ways. What is the most out-of-the-box thing you can think of to deal with this issue?

• Subcutaneous source of truth. Implantable RFIDs would transmit information to medication administration tools, providing an accurate indication of what was taken and when.
• Go to the source. Deal with discrepancies between the single source of truth list and what the family tells you by requesting information from the original prescribing physicians, and have them help in the PTA process. Widen the circle to include the entire team involved in taking care of the patient.
• Make it the patient’s responsibility. The PTA could be a patient-centered, patient-created and patient-maintained medication list. Physicians would then confirm rather than generate the list.
• Smarter meds. Computer chips in medication bottles that would include dose strength, time to be taken, and other information.

Patient discharge

Discharge is another problematic piece of medication reconciliation. Orders are done at 8:00 p.m. for a patient to be discharged the next morning. In the order, the patient is told to stop taking a beta blocker and see his primary care practitioner in five days to determine whether to restart. Also, an oral antibiotic is prescribed for the patient, but at the time of discharge, the patient insists these pills make him vomit and the prescription needs to be changed. The medication reconciliation has been done, but needs to change.

How do you document this in a codified fashion?

• Partial reconciliation. Regarding the antibiotic question: One suggestion would be in that instance, it’s really a partial medication reconciliation that indicates only the med being changed out, and as long as that’s the only thing that’s changing, you don’t need to re-reconcile every medication.
• Starts and stops. If start/stop/continue are the categories, we’d say the beta blocker would be listed under Stop if it was a home medication that we were stopping, and we’d have to put a comment in saying something like ‘may have MD restart it; follow up.’
• More options. There are many situations where a medication needs to be held for something. In addition to stop/start/continue, the system needs an additional status of “hold until” or “hold because.” But the system still has to consider that intermediate state and must have rules for that.

Next-generation healthcare IT

How should we design the next generation of healthcare IT to enhance the connection between healthcare providers and patients?

• Interactive PHRs. Use information in the EHR displayed graphically to engage the patient, and use PHRs in a collaborative way, with a combination of push and pull technology, so we’d be alerted if patients weren’t doing what they were supposed to do, and patients could communicate back with us.
• Service-level agreements. Patients need to have a service level agreement with the doctors. The patient has to be confident he’ll get a response from the provider.
• Clearer interactions. Provide a translation function so patients can navigate their medical record and can get help where needed translating any physician-speak. We must also reduce the redundancy in questions that we ask.
• Communication communities. The patient’s significant other, advocate or parents need to hear what’s being communicated to the patient. We also need to extend communication to include care groups, specialists and providers. It could be a shared platform, that expose questions and answers with branching logic.
• Non-intrusive technology. The computer is often between the physician and the patient; we want to move it into the background. It also has to be something we can quickly make notes on or pull information from, or toss aside quickly.

And we have to lower the learning curve, so there has to be more standardization among products. Right now, even if you get into a car you’ve never been in before, you’ll probably know how to drive it. You can’t always walk into a hospital and use the EHR.