Technology blockers on the way to patient centered care.
One of the fundamental transformations of the European healthcare system is a changing position of a patient vs. a physician. A physician, traditionally perceived as a Demiurge able to decide on life and death due to the unique knowledge of Ars Medica he possesses, is giving space to a patient, whose previous role was to submissively tolerate procedures imposed on him. Hence the word “patient”, not “person”, adopted in medical environment.
Consumer-oriented technologies such as smart phones, tablets, etc. intrinsically support the concept of a “patient centric care” which means granting more decision power to people through the ability to access personal health data, search for an appropriate doctor or verify their diagnoses. By pushing their gadgets with applications into the environment previously dominated exclusively by professional medical devices, consumers are gradually becoming one of the key drivers of the whole healthcare market making it more patient oriented and human. But there are several blockers on the way.
Blocker 1. Patients’ disengagement of the Health Information System (HIS) design.
By influencing business processes HIS has a unique ability to guide and drive the user’s business behavior. Consequently, if HIS does not stimulate users to behave differently, they will run their business in the old way. Thus, according to American Hospital Association survey 2014, 80% of provider organizations have some type of basic EHR (Electronic Health Records) in place, but only about 35% had “comprehensive” systems rather than merely the ability to share clinical notes.
HIMSS EMR (Electronical Medical Records) maturity adoption model shows that only 217 hospitals (around 15 percent) of the total 5,627 US hospitals have achieved the EMR 7th stage thus, according to the stage requirements, being able to share health records with their patients.
Physicians are often part of the development teams as testers or consultants. If a doctor does not get what she/he needs with more than one or two clicks the system is not worth working with. Patients, on the contrary, have much more limited representation in the development process. But after all, who is the one who will ultimately endure the outcome of medical procedures? Why not putting patients on board of the software design teams to enrich the system from the very start with patient oriented services such as homecare or remote monitoring.
Unfortunately, so far efforts to create Personal Health Record Systems (PHR) destined to capture individual’s preferences or complains are running in parallel to HIS or EHR developments. A future integration of such systems could be a nightmare. Not only interoperability and security pose great challenges, but most of the physicians rightfully do not trust the data received from external sources. After all, how those data were obtained? For example, was a patient sitting, standing or exercising while her/his blood pressure was taken? How reliable was the device that was used?
There are some good examples of clinics that start enriching their EHR and HIS with patients’ PHR. For example, Mayo Clinic personal health information tool is offered to patients as services enabling them to view the “results and records as fast as your clinician does”. Medical Archive – a Personal Health Record application – designed by a group of enthusiasts from the Moscow Hematology Institute helps patients to review treatment procedures discussing, together with clinicians, the latest lab test results for the sake of the overall outcome improvements. Unfortunately, such practices are not yet wide spread.
If health information systems are to drive clinicians towards new behavior and patient relationships, the approach should be embedded in HIS from a very beginning rather than piecewise mending various parts of EHR, EMR and PHR later.
Blocker 2. Incompatibility of traditional business processes and Digital Era.
One cannot drive a Harley Davidson the same way one rides a bicycle. The present care delivery model does not fit the Digital Era goal of offering accessible health services to many anytime anywhere. Doctors will hesitate to provide online consultancy if their compensation is based on a number of face-to-face visits (model existing, e.g., in Germany). Similarly, a US physician whose licenses are tied to Nebraska would not be able to support patients in Alabama.
The long-awaited personalization of care promised by the Internet of Things or by personal genomic studies clashes with the traditional insurance compensation based on “one size fits all” practice.
Hospitals and physicians who are receiving premiums from insurances for each operation performed, even the unnecessary ones, are hardly an example of a patient-safety approach. Thus, the German Health Insurance AOK 2014 report provoked indignation among both physicians and hospitals when it revealed that 19.000 preventable hospital deaths in the country were annually happening as a result of operations that could have been avoided. For a comparison: car accidents took away the same year 3.290 lives.
ICT could catalyze new methods and positive behavior shifts in healthcare, but if it supports fruitless business process, it can be a guardian of stagnation.
Blocker 3. “Digital fears”.
True, current EHR systems are still much to be desired in terms of their friendly look and feel. But let us also not underestimate another reason: a deep belief stemmed from the long history of medicine that a doctor belongs to the sacred guild with an untouchable authority. Technology brings transparency, including the disclosure of medical errors that makes the authority relied exclusively on belonging to a professional group vulnerable.
Despite all technological innovations, it is often a human factor that decides on what “to be or not to be”. How often have we heard from physicians that EHRs slow them down by forcing to tangle with complex interfaces instead of spending time with a patient? According to a American Medical Association and the American College of Physicians’ American EHR division., about 34 percent of physicians said they were satisfied or very satisfied with their EHR in 2014 whereas 72 percent believed their EHR made it difficult to very difficult to decrease their workload.
I was once visiting the newly renovated hospital in Munich with SAP Healthcare system installed across its departments. To my surprise, the Intensive Care Unit (ICU) staff was not able to access records of a patient who was brought to them from the cardiology department. Nor cardiologists were able to access records of the same patient who had been previously treated by neurologists. The clarification was astonishingly simple: if a clinician uses data provided by another clinician, he should be prepared to share information about his/her own patients. Something, as I was explained, many physicians do not want due to the fear of transparency. Thus the “continuity of care” could simply bump and break against the human desire to protect one’s territory.
Contrary to physicians, the majority of patients have a different attitude to EHR. A survey launched by Nuance found that 97 percent of patients are comfortable when their physicians are using EHR. Moreover, according to ReferralMD, 54% of patients are very comfortable with their health providers seeking advice outside, even from online communities, to better treat their conditions. Such activities in no way undermine patients respect towards their physicians.
The information technology can support and drive positive transformation in healthcare. But it is not a magic. It is just a tool that could be used to get a better insight into clinical history, provide better diagnostics and successful treatment. It depends in whose hands the tool is and whose interests it protects. Ideally, it should be in the possession of both patients and medical professionals united by the common goal: to find a right treatment for the right person.