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Healthcare in the Heartland

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Affordable-Care-ActWhen I’m not heads down in data points on how hospitals around the country are going mobile, I spend time volunteering as a clinician with the Rural Health Clinic of the Cumberlands, a free clinic for the underserved community in my neighborhood in Cumberland County, Tennessee. So, the challenges facing rural hospitals and health systems today are both a professional and personal interest of mine.

Today, the majority of STEMI patients – up to 80 percent – are unable to get to a STEMI receiving hospital within 60 minutes. The country’s rural healthcare facilities are critical to delivering care to a number of underserved communities. But with nearly 40 million new patients entering the system under the Affordable Care Act, and smaller community facilities under threat of acquisition by larger health systems, it’s time for rural hospitals to go on the offensive.

Healthcare consolidation is like picking a team in gym class – you don’t want to be the one picked last, you want to be the captain. In most cases, larger health systems take the lead in developing rural outreach strategies to acquire smaller hospitals. Instead, rural hospitals should be proactively forging relationships with larger academic medical centers or heath systems that are aligned with their missions and can provide the best quality of care to their patients. Partnership selection should vary depending on the need to deliver care to specific population sets like cardiology, pediatric and neurology patients. By becoming more sophisticated and proactive about the partnership process, rural community hospitals will gain a sense of power in the relationship. They can also supplement what they don’t do well by partnering with the organizations that do– and that will allow them to deliver better and timelier care at any given moment, rather than trying to stand alone.

In partnering with these larger health systems, rural hospitals also need to leverage technology to “virtualize” clinicians while increasing time at the bedside. For some people, adding more technology to the mix and shifting the focus away from the patient and onto a computer or tablet screen seems to run counter to the idea of providing better care. But when used well, technology can get more physicians at the bedside when needed and improve interactions with patients. And, as clinical collaboration and care extends beyond the four walls of their own facilities, access to both live and historic records and diagnostic-quality data will be critical to ensuring a seamless and successful partnership with larger health systems.

Healthcare has become more competitive than ever and rural hospitals have their work cut out for them. But by becoming more strategic in their partnerships and evolving their technology systems, these facilities will be in a position to thrive and continue to deliver quality care in the heartland.


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Old is the New “New” – Engaging Physicians Through Mobility

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ImageAs incentives increasingly align between physicians and hospitals for value-based care delivery, health system CMOs face an interesting challenge. The last one to two decades witnessed an extraordinary push to hyper-specialization and compartmentalization of care.

Physicians migrated from round-the-clock response to their personal patients to team call coverage models, and patients were handed over to hospitalists when admitted. Drivers for this shift included financial, efficiency, lifestyle and quality factors. Now, risk-based models are aligning incentives for greater care continuity by physicians for their patients both in and out of the hospital. In many ways, CMOs are asking for an old school approach to meet quality and cost goals. Providing innovative tools can help achieve this – systems can engage physicians for greater continuity while protecting lifestyle and workflow preferences, and mobility solutions will play a key role.

In the shift to risk, a key objective for CMOs is to get physicians and hospitals on the same page – where they are both incentivized for quality and cost efficiency goals. But in practice how does that actually work? Inpatient care teams can benefit from the deep knowledge and context held by primary care physicians, but that’s not happening effectively, resulting in care duplications and inefficiencies. Primary care physicians who still maintain responsibility for their admitted patients only see them for a few minutes after office hours, but are disconnected throughout the day. More often, the pendulum has swung in the opposite direction, where inpatient care is turned over to hospitalists who typically don’t have access to rich outpatient data. That’s not the right solution either.

Something is needed to merge the inpatient and outpatient worlds in real time, and mobility is that bridge. If physicians are incentivized for the total cost of a patient, they need the tools to help them achieve that incentive. An effective mobile strategy enables doctors to operate in multiple environments by getting them the data they need when they need it to make critical decisions.

Physicians need to be engaged in the process change early, so that they understand how the technology is enhancing patient care and their workflow. Physicians don’t want to be inundated with data or unnecessary interruptions to their day. They want to just get the right information on the highest-risk patients and be able to make care decisions on the same device that they were notified on. For example, if a primary care physician gets a notification on their phone that a hospitalist is going down a treatment path for a high-risk patient that has not worked in the past, they should be able to alert the hospital care team with key information from the ambulatory record and start coordinating in a fast, efficient way that makes a difference.

That’s when we will start seeing groundbreaking improvements in cost-savings and quality that will allow hospitals to share risk with physicians and payers more effectively. If CMOs want to make an impact today, they need to stop thinking about mobility as something that will happen in the future, and start thinking about how these innovative approaches can improve care pathways and address challenges like physician engagement that are happening now.


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An Industry Retrospective Demands a Call to Action

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nhitweek_avatarWith National Health IT Week underway, I’ve been thinking a lot about the state of the industry. But when I look back over the last several months, rather than progress, I see mounting challenges and pressures. There have been several incidents that have contributed to the financial strain hospitals and health systems are facing, including:

  • Introduction of reimbursement penalties – Almost exactly a year ago on October 1, 2012 the readmissions penalties included in the Affordable Care Act kicked in. The penalties place enormous pressure on hospitals and health systems, especially in the cardiology service line. This has served as a motivating factor for population health efforts for providers to continue to care for patients once they have left the hospital.

  • Uncertainty over national leadership – As readmissions penalties went into effect, the pending election caused uncertainty over whether the reimbursements would continue, which in turn caused hospitals and health systems to worry about their expenses. Once Barack Obama was re-elected, it became clear that the ACA measures would move forward, and that hospitals and health systems needed to begin bracing themselves for the 40 million uninsured patients about to enter the system.
  • Sudden onset of sequestration – Just as hospitals and health systems were adjusting to health reform changes, they were hit with an unexpected challenge on April 1, 2013 – sequestration cuts. Basically, sequestration doubles the healthcare cuts put in place by the ACA, with $2 billion in cuts for 2013 and an expected $9 billion in the coming year. Sequestration is going to contribute to the ongoing industry consolidation, because hospitals that can’t stay in business are going to sell into larger health systems. Which brings me to…
  • Continuing industry consolidation – The past year proved that industry consolidation is going to be an ongoing trend. The June purchase of Vanguard Health Systems by Tenet Healthcare was one of the largest acquisitions the industry has seen. While consolidation is a solution to financial pressures, it also reinforces the challenge of interoperability, given that facilities’ EHR systems are not going to play nice without optimization.
  • Preparing for the future – Throughout the past year, providers have been plagued by the looming challenges of Stage 2 Meaningful Use and the ICD-10 transition. While facing cost cuts, hospitals and health systems are under the gun to get the technologies and process changes in place necessary to meet these two upcoming regulations.

These increasing pressures bolster the need for health IT to help hospitals and health systems improve ROI to compensate for financial cuts and challenges. We all need to realize that the biggest ROI comes from leveraging the existing infrastructure. It is all about optimizing - not replacing – your existing EMRs and medical devices. National Health IT Week is a great forum to build awareness for the value of health IT, but it’s also an opportunity to foster collaboration among vendors. Increasing industry tensions will require health IT vendors to change their ways and start collaborating with each other to offer the solutions providers need now.  Collaboration does not come from creating imaginary consortiums but by supporting providers on their current integration needs.


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Partnering for the Future of Healthcare

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health-careFor hospitals and health systems to achieve the value of their EMR investments, they must be able to deliver information to the point of care and ultimately the point of making a difference with patients – whether the clinician is at the bedside, down the hall, in the office or at home. Industry paradigms like health system consolidation and the physicians shortage mean that clinicians will be increasingly mobile, relying on personal devices for the information they need to provide quality care.

What we know today is getting information into the hands of clinicians in the right place at the right time isn’t going to be easy. That’s why in July, Microsoft was pleased to announce that AirStrip will be the first mHealth company to be part of the Microsoft Apps For Surface program. Innovative leadership like AirStrip’s is essential to overcoming the challenges of mobile healthcare such as like compliance, regulations and interoperability.

Microsoft is engaging with healthcare vendors who understand the changing industry and are bringing new solutions to the table to help clinicians improve the quality of care while reducing costs. We want clinicians to have the tools they need to make care decisions right on their Windows 8.1 devices including a seamless view of EMR data and medical device data. Clinicians need enterprise-class software available on Windows 8.1 devices that enable the security and functionality necessary for the exchange of patient data.

Working toward this vision, during Health 2.0 we announced the next phase in our relationship with AirStrip – the availability of AirStrip ONE Cardiology for Windows 8.1. When we talk with hospital and health system decision makers, we recognize they are juggling financial pressures and need to prioritize health IT projects to confirm the value and ROI. The cardiology service line is a good place for health systems to get their feet wet in mobility since the data lends itself well to visual representation, cardiac conditions are a target for readmissions penalties and cardiology patients tend to be an expensive patient population.

One of the most impactful components of making AirStrip ONE Cardiology available on Windows 8.1 is that it’s not just going to reach clinicians on their tablets but will also make that same view of data available on their desktops at the hospital and office.

We’re excited to continue to grow this relationship with AirStrip and to work with together to deliver the solutions that meet the current and future needs of the evolving healthcare system.


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The Key to Success: Maximizing Information Technology

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mitcon-photo01fullAs we gear up for HIMSS at the end of this month, we tend to think back to who has been dominating the healthcare conversations over the past several years. The answer is obvious: EMR vendors. Meaningful Use guidelines have been driving towards the adoption of EMRs and encouraging clinicians to adopt technologies to enhance patient care. But these tools are transactional, not transformative. For an industry that is cutting edge in so many ways, we’ve struggled to successfully crack the code with informational technology. Customers are constantly telling me that we need to find ways to make the data work for us, to improve healthcare.

As new technologies and the BYOD trend have worked their way into hospitals and health systems, we’ve begun to find patterns in what is necessary to launch successful programs. The key? Ease of use for clinicians and clear benefits to patient care.

To reap the rewards informational technology has to offer, clinicians are exploring the potential of their various devices in the workplace. These different tools need the same things: compelling and safe user interfaces that offer an easily managed experience. Clinicians need access to information anytime and anyplace to address questions and make clinical decisions. At the same time, while we may agree that tablets are not just a fad, that desktop dominating your desk space still remains the major player in day-to-day care. The enhanced, slick experiences that vendors are providing for mobile apps need to be reflected in desktop offerings as well to satisfy users.

Additionally, patient care is not handled by one doctor alone. Care teams need to be able to coordinate and collaborate. The full care team should be able to connect on clinical issues in whatever way they choose, while still having access to all of the same clinical data in near real-time. From the cardiologist to the nurse, from the office to the bedside, communication should be clear and consistent to address patient needs.

Delays in these developments and concerns around privacy or security have held up the healthcare industry’s advancement in many ways, but the promise is out there. When vendors and health systems put the patient first and look at how coordination and access to insightful, actionable data can improve quality of care and patient satisfaction, we can move beyond IT issues to truly transform care.

 

Neil Jordan is the general manager of Health for Microsoft Worldwide Public Sector. In this role, Jordan acts as chief strategist for the organization’s health industry initiatives worldwide, including defining and articulating the Microsoft vision for the future of healthcare and how Microsoft products, technologies and partner solutions will make it a reality.


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Data-Driven Evaluation of Mobility’s Impact

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nextgov-mediumHealthcare is rapidly evolving, and more than ever, hospitals are under extreme pressure to continuously identify ways to improve performance and justify every expense. In this type of environment, technological innovation alone will not prove sufficient. Instead, making sure technology is successfully implemented and processes are streamlined to ensure adoption and maximize value becomes the currency of improvement.

Tools are developed with a particular purpose, but clinician experience and alignment determine compliance. Without clinician support and adoption at critical mass, any new IT strategy – whether it be electronic medical records or mobility – can be disappointing. Because of this, tracking how and why clinicians leverage mobile offerings – from expediting care to proactively monitoring patients – provides hospital administrators with some insight around the ways users are influencing patient care and achieving value.

Once this record of tracking is compiled and contextualized, the data can be shared with leaders within the organization. Charted visualizations of achievement milestones and benchmarks are a useful way to outline valuable patterns and specific examples of where mobility usage is effectively being implemented or can be strengthened to improve care. Proactive monitoring of utilization offers hospitals and health systems actionable insight to drive their desired adoption of mobility strategies. Visual displays of actual live, historic and trended data about monitored patient populations can both support patient care improvements and achieve administrative goals.

There is no substitute for the transformation of data into useful information and knowledge in order to inform health care leaders as to how, when, and why their clinicians are using IT solutions to improve patient care. Moving forward, the industry will be developing comparative benchmarks across health facilities. A deeper understanding of how deployed solutions and tools are being used is necessary for true clinical transformation.


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Cerner/Siemens and Blue Shield/Blue Cross: What Happens Next?

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The industry is buzzing over the news that Cerner is buying the health information technology business unit of Siemens. The Siemens acquisition is the most recent high-profile example of consolidation that is taking place in all sectors of healthcare.

The consolidation trend is not new, of course. Providers reacted first, by aligning as Accountable Care Organizations (ACOs) and clinical integration (CI) networks during the past five years. Then the passing of the Affordable Care Act (ACA) accelerated the need for collaboration, forcing providers to acquire additional acute care and post-acute care facilities as well as physicians’ offices. This consolidation trend was the first to expose the obvious lack of interoperability amongst vendors.

Market forces are leading to the tightening of operating budgets and driving the movement toward patient-centric, outcomes-based reimbursement models. The challenge is that millions of patients are coming into the system at reimbursement rates below cost. In this environment, clinician shortages are also a serious and ongoing concern as the emphasis should be around better management of population health. In turn, this is spurring consolidation in all sectors of healthcare at a blistering pace.

Now vendors are getting into the act, as evidenced by the Cerner/Siemens announcement. The industry is clearly moving toward fewer big vendors controlling more of the HIT marketplace and likely snapping up the smaller vendors, while focusing on selling their offerings to smaller community hospitals. This is a recipe for fiercer competition and less cooperation. What will get lost, I fear, is any sincere focus on interoperability (health information exchange) and true collaboration.

The Siemens acquisition is big news, of course – but there is another story this week that is just as important, and the latest indicator of the need to accelerate all interoperability efforts. Blue Shield of California and Anthem Blue Cross announced that they are creating one of the nation’s largest health information exchanges. Becker’s Hospital Review reports that participating providers in California will have access to more than nine million patient records via a portal compatible with most electronic health record (EHR) systems. Blue Shield and Anthem Blue Cross are funding the first three years of the program at a cost of $80 million. This announcement is a move toward next-generation interoperability and data sharing.

Both announcements, combined with the strong market forces, validate the urgent need for innovation around interoperability, analytics solutions and vendor-agnostic mobility. But the key question is, “Who has the ability to lead this transformation?” As technology vendors, our role is to enable the transformation. However, the responsibility to drive it should never be given to vendors.

Payers and healthcare providers have the upper hand here. They also have the social responsibility to force vendors to open up and support interoperability standards by leveraging their strength resulting from the fast-moving provider acquisition market. Failure to exercise that power may lead to patient population leakage, which in today’s environment of shrinking budgets and evaporating margins would be catastrophic. Providers can take the lead in enforcing interoperability standards, while supporting accelerated deployment of agnostic mobility and big-data analytics tools.

Vendors that support true openness, neutrality and collaboration – along with the ability to positively impact workflow – are best positioned to thrive in the years to come in this era of industry-wide consolidation. The need for interoperability is stronger than ever, and payers and providers have the power to ensure this happens.


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Staying Ahead in a Technology-Driven Field

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Since patient care and well-being is at the center of Rockdale’s mission, attracting the best and brightest clinicians in the region is an important effort for us. Part of distinguishing ourselves from our competitors is providing the resources and advanced technological support clinicians want. In fact, to support this shift, we formed the Information Technology Physician Engagement Group in 2013 to identify exactly what were the technology priorities for our physicians:

  • Improved cellular service
  • Improved physician Wi-Fi
  • Single sign-on access
  • Mobile technology for better efficiency

From our perspective, we realized mobility is no longer an added bonus for physicians and nurses, but a necessity. Consequently, we’ve implemented a mobile strategy to address these needs and meet the new expectations of the latest medical recruits.

Hospital staffing structures are not what they once were. Our medical staff is actually fairly complex, with many physicians part of groups and not frequently on-site within the hospital. Thanks to mobility, physicians can be off-site, in their offices doing day-to-day work, and still able to see patient data in near real-time, as well as access patient records. Since many of our clinicians practice across multiple hospitals, particularly those in our obstetrics service line, this remote access to patient data has become a differentiator for Rockdale. If there is a choice to have a patient deliver her baby at a facility where the doctor can remotely monitor her condition as he makes his way to the hospital versus one where he can’t, the choice is fairly simple.

Additionally, with a shortage of clinicians in the U.S. and the near-retirement age of many of our own physicians, attracting the next generation of recruits is important to filling the care gaps. These newer physicians are extremely computer-savvy and used to having their mobile devices on-hand at all times. For them, having patient information accessible at anytime from anywhere is no different from the rest of the information they consume in a day – technology within the hospital is expected.

We are consistently working to plan ahead and anticipate the needs of our physicians. With our current strategy we’re supporting compliant workflows, improving care coordination, and supporting expedited care in emergency situations. We’re now working to add additional clinical support, like ordering directly from mobile devices and connecting additional patient data sources.  As we work with our Physician Engagement Group moving forward, we hope to continue to support of doctors’ needs so they can focus on providing the best care possible and keeping our patients safe and healthy.

Dr. Lisa Gillespie, MD, is the Chief Medical Officer at Rockdale Medical Center. She specializes in internal medicine, currently treating patients in Brentwood, Tennessee and Conyers, Georgia. Dr. Gillespie has 16 years of experience and practices in internal medicine and hospitalist.


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The Evolution of Health IT

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Health IT is often considered a silent partner in healthcare – not seen by patients, but a critical part of the system. As we celebrate National Health IT Week, it’s important to realize that although health IT already has a long history, the constant and rapid evolution of this space continues to transform the market. Information has been collected and stored for years, but the promise of clinical decision support has us at the cusp of all this information becoming valuable in new and innovative ways.

Just a decade ago, I was documenting patient encounters in paper charts. Although the transition to electronic medical records (EMRs) has been perceived as slow, in the grand scheme of medicine it actually happened almost overnight. These systems were not designed with our continuously changing workflow in mind, with user interfaces and workflows that aligned to our practices. They served as repositories for patient information, but did little else. In fact, our workflow changed to support the EMR, sometimes to the detriment of the patient. Instead of focusing directly on the patient, we often must split our time and attention between the patient and the computer terminal.

Today, technology that supports clinical workflows is becoming the norm. Although mHealth is still in its early growth stage, it is growing in a way that supports customized clinician workflow. And, importantly, it brings patients into the equation by empowering them with their own health data and the ability to reach out to their care team when the data is confusing or concerning. Health systems and hospitals are beginning to see the value of these applications, and are adopting new attitudes and strategies that truly leverage technology to improve patient outcomes:

  • It is increasingly common that hospitals allow the use of smartphones and tablets within their four walls.
  • Healthcare has become more accepting of mobility at it becomes the norm across other industries. From shopping to banking, other markets have served as case studies for healthcare to observe and learn from, particularly regarding security issues. Though security concerns are still high, the more accepted mobility is in other spaces, the more it is becoming expected within healthcare.
  • Implementing mobile strategies means quicker and easier access to patient information. For example, clinicians are now able to access live and historic patient information on the fly, while walking to the patient’s bedside, and share the data with the patient in real time. These workflow efficiencies result in more time for the patient and less time accessing multiple data sources.
  • Healthcare is starting to emphasize the need for better health overall, not individual episodes of care. This shift has encouraged clinicians to value information from a variety of sources across the care continuum that more accurately represents a patient’s overall being.

From my own physician perspective, Health IT and mHealth allow me to immediately access the right data at the right time, in order to make efficient, data-driven evaluation and treatment decisions. By providing many of these same tools to patients, they become empowered to monitor their own conditions and can reach out to their care team when appropriate. In this manner, we are truly practicing patient-centered care.

The future of health IT will incorporate patient data from a multitude of sources across the care continuum, and present the data to clinicians in a triaged, value-added manner. These clinical decision support tools will allow proactive monitoring of patients regardless of location, warning the patient and care team of potential concerns, and expediting the treatment of the patient at the appropriate level of care.  We are just beginning to tap into the power of health IT and with its integration into clinical workflows, we will soon witness significant improvements in the state of our health.


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Data, Data Everywhere and Not a Drop to Drink

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Clinicians want two things from data. On an individual patient level, they need to be able to see the data whenever and wherever they want – in a clean at-a-glance format and with essentially zero lag time. And at a cohort (population) level, they want the data presented as meaningful information in a way that enables conclusions, decisions, and actions about a group of patients.

These statements may seem like self-evident  Data 101 to many of you, but in my decades of experience working clinically as an emergency physician and being responsible for operations of multiple emergency departments, it is clear that we have not delivered on this vision. In fact, the healthcare world lags other industries by 15-20 years in the availability, presentation, and use of information. Although our industry is catching up, there is still more effective use of information technology in banking, aviation, on-line retail, and a multitude of other industries. Even though many of the concepts of optimum presentation and use of data have been around for decades – the quest for electronic health records began in the 1980s – their breadth of execution and the realization of their value propositions have not been sufficient to become the norm. Healthcare has moved at a glacial speed of change, at least until recently.

In developing technology to improve healthcare, there are two things to consider: how it improves patient care and how it affects clinicians. One of our drivers at the MedStar Institute for Innovation, is the creation of information platforms that provide care teams with near-instantaneous access to all relevant data, regardless of source, that is relevant to a clinical care decision. Years ago (circa 1996), my colleague Craig Feied, MD and I developed Azyxxi, a clinical information system that was first used at the MedStar Washington Hospital Center emergency department. Its design was driven by our realization that clinicians spent 30-40 percent of their time just looking for information. If we could make any item of data concerning a patient available in less than 1/8 of a second (so its access would feel essentially instantaneous), we knew that the clinician experience would flow and that the time not spent in search or wait mode would be better spent using that data to make the appropriate care decisions.

By eliminating data silos, creating simple and sleek user interfaces, providing data in context, and using human factors design principles to bring the important data to the forefront of a clinician’s ken, we can improve care. We can make better clinical decisions faster, we can “miss” less important information, and we can make care safer by reducing the number of actions or inactions which can have serious consequences on a patient’s well being. In healthcare, it’s not good enough to get it right 99 percent of the time, i.e. miss things at a one percent rate. For every patient in whom a preventable adverse event occurs, that error in care happens 100 percent for that individual, who must live with the consequences forever.

To design and build information tools that support optimum care, it is important to consider what physicians and broader care teams really need – and only what they need. More is not necessarily better. Signal is easily overwhelmed by noise. The patient is ill-served by a drive for completeness if an item of data that represents critical information is buried in a welter of unimportant information. Clinicians understand what they really need to know and when they need to know it. They know what it is they have to go hunting for and what would make sense to bring to the forefront.

And while many of us may think we have a clear understanding of what needs to be done, based on our own needs and analysis, working within a liquid network of other like-minded clinicians and outside vendors who know how to develop and deploy technology effectively will give us the best chance of success. Partnerships with vendors can enable us to build on their previously existing platforms and to share and spread transformative tools and best practices among healthcare facilities. In this way, we can work together to bring healthcare up to a “use of data” standard enjoyed by other industries.

As the African proverb says, “If you want to go fast, go alone. If you want to go far, go together.” Let’s go together.

Mark S. Smith, MD, is director of the MedStar Institute for Innovation (MI2). In this role, Dr. Smith leads a system-wide initiative to foster and catalyze innovation at MedStar Health. In addition, Dr. Smith serves as professor and chairman of emergency medicine at the Georgetown University School of Medicine and is the former chair of MedStar Emergency Physicians.


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Harnessing the Power of Big Data with Digital Health Partnerships

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KWard_dataIn today’s digital world, electronic patient data is growing exponentially and moving faster than healthcare organizations can imagine.  At the same time, clinicians suffer from information overload, and high-volume and increasingly complex clinical patient loads, alongside dwindling time and resources.

Now more than ever, the pressure is building to harness the power of big data and digital technologies to help clinicians make faster, patient-centric decisions that increase quality of care and enhance health outcomes all while decreasing costs.

Sounds great, right? Especially to the critical care domain where data is extraordinarily dense, time is our greatest opponent, and fiscal concerns represent an annual cost to the U.S. economy in excess of $260 billion and approximately 40 percent of total inpatient costs.

But what if health care analytics and clinical decision support (CDS) could combine to deliver rapid bedside diagnostics or upstream health detection capabilities?  That is to say, a tool that provides first responders, clinicians, hospital staff, home care providers, and patients with clinically relevant, patient-centric information, intelligently filtered and presented at appropriate times to transform care delivery.

Historically, CDS applications have operated as components of comprehensive electronic health record (EHR) systems—in other words, retrospective data repositories or order entry systems with limited data streams that are, at best, semi-real time.

However, the next generation of CDS tools seeks to incorporate advanced data processing systems capable of discovering and harnessing actionable insights from all varieties of medical data, and leveraging these insights for diagnostic, predictive and prescriptive capabilities.

In a nutshell, this next gen CDS tool will aggregate disparate patient health information—static and real-time—across care delivery touchpoints for analysis and optimization, enabling clinicians to make faster decisions and implement personalized, patient-centric treatment options at the point of care, whether that is the home, ambulance, hospital or battlefield.

Bear in mind, this description simplifies what is a highly sophisticated and complex health IT tool to a functional concept. Key challenges for implementation include the ability to:

  • Collect and aggregate health data, including that from monitors, throughout the patient care continuum into a single portfolio
  • Normalize, pre-process and de-identify data for analysis—not all data is created equal and not all data is useful in its raw form
  • Capture data at the point of care, stream for real-time computational analysis and combine with retrospective data
  • Present actionable insights in a format that end-users can easily consume for enhanced decision-making in the clinical workflow or home life-flow

Ultimately, such a solution could have the power to save a life, elevate care delivery, reduce length of stay, improve quality of life or predict and avoid a critical health event altogether.

To many, this sounds almost like science fiction, but probable with the help of a small village—or in our case, a team of digital health partners comprised of world-class researchers like those at the University of Michigan, advanced analytic technology products, wearable and anti-wearable sensors, and mobile and connected health solutions.

Healthcare has lagged behind the retail and financial sectors in the use of big data and digital technologies but the gap is closing and closing fast. The risks are high, but manageable through the teaming of digital health partners, and worthy of such a high-impact payoff.  Data is king and the more hard evidence we have the better decisions we can make as clinicians, patients, families, providers, payers and industry alike.

Kevin R. Ward, MD is the Executive Director, University of Michigan Center for Integrative Research in Critical Care and Professor of Emergency Medicine, University of Michigan Medical School.


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Transformation in 2015: Focusing Technology on the Patient

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We are currently experiencing the biggest transformation in healthcare ever. Technology plays a significant role as an enabler of this transformation, but will not drive it alone. Improving patient care and driving toward patient engagement are crucial goals in this next phase of the healthcare industry. To make adoption ubiquitous and implementation effective, there are several things we should focus on as we dive into 2015:

  • Real-time clinical decision support will transform care: As even more patients in need of care move into the system because of the Affordable Care Act (ACA), the amount of data needed by healthcare professionals to improve care will increase by an order of magnitude. The impact of adding more data to a limited number of caregivers means that the top technologies to enable clinical transformation will be data aggregation, big data analytics tools, and real-time processing engines. The ability to collect and analyze clinically relevant data on a near real-time basis and visualize via mobile devices will empower clinicians to make faster, more confident care decisions.
  • Wearables can take on a new life: mHealth applications have become accepted – and almost expected – in the hospital environment. The same level of secure, diagnostic-quality medical device connectivity should also make its way into the home to support remote monitoring and population management. There are some impressive technologies from the research community that will revolutionize the way we monitor patients and manage diseases beyond the four walls of the hospital. This includes disease-specific body sensors and implantable devices that can collect and transmit a wide variety of clinically relevant data on a near real-time basis to the caregivers. At the same time, while activity monitors like the FitBit and Nike Fuel have thus far been geared toward healthy (and competitive!) people – not sick patients – there is a home for them in chronic disease management. By connecting this kind of data to a real-time analytics engine and a patient’s EMR, the care coordination team is armed with a list of priority patients who are not following their prescribed activity protocol that the team can follow-up with and work to remedy.
  • Patient data should be protected like financial data: When dealing with mobility, it is crucial to consider the way data is protected. Patient data is highly valuable, and should be treated as such, and protected the same way mobile access to a bank account is secured. When a person accesses a bank account on a mobile device, there are layers of encryption, including a token that dictates that every 30 seconds both the device and the bank change the password and sync again – a high-level of security beyond normal standards. Patient data should be protected with similar standards that offer layers of security at all levels: server, client, transmission and authentication. HIPAA rules for mobile technology were written in 2003, and we should consider that anything that was written before the release of the first iPhone to be obsolete.
  • Hospitals and health systems will guide innovation: Whether we are caregivers, payers or vendors, we are also consumers of mHealth. Therefore, we share the responsibility to transform healthcare. The first step toward that goal is to unlock clinical data from legacy systems. Without interoperability, there is very little chance for success. This seems to be a hot topic in the industry. Many are talking about it, but unfortunately very few legacy vendors are actually advancing the cause of interoperability. This is a mission-critical task.

In my view, 2015 will be the year where providers will have the opportunity and power to lead the industry and force legacy vendors to open up and truly collaborate, instead of just talking about it.

Provider consolidation and collaboration is creating much larger healthcare organizations with a strong need to integrate in order to better manage population health by both clinical condition and market. This trend is further exposing the lack of interoperability, but at the same time is creating an ecosystem of providers that is gaining a degree of power never experienced before. These providers have the power to drive healthcare costs down, improve the quality of care, guide the federal government on introducing and enforcing standards, force vendors to comply with those standards and, eventually, transform healthcare.

That shift of power that we are seeing today will shift yet again if providers do not take advantage of their ability to drive transformation. As data consumers, the patients could take control by refusing to engage with those healthcare organizations that fail to bring transparency to their data. The ultimate goal for healthcare providers is to maximize patient population, and only those providers that drive and innovate will achieve that goal.

The healthcare industry seems to be forever changing, but with the right approach and some forward thinking, 2015 could be the year of transformation and transition – when the patient really and truly becomes the focus of care.


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Future of Health Care: Keeping the Patients in Mind

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imagesThe key to successful health care technology is making sure it improves both the patient experience and the quality of care. While technology is sometimes seen as a barrier to human connection and interaction, the right tools can transform the health care experience for the patient. At Dignity Health, our focus for 2015 is centered on making population health a reality by looking toward the ambulatory side of care. The mobility strategy we put in place in 2014 is enabling us to empower our providers and care teams with telehealth solutions so they can have alternate ways to connect with and care for their patients.

As we take on more risk and value-based contracts, we need to manage our patients’ care differently than in the past. We need to provide cheaper and more convenient care to a bigger population. Today, the typical doctor’s visit requires a trip to the brick-and-mortar office location. However, there is a significant opportunity to better engage patients and encourage them to seek medical attention by conducting virtual visits. We should work to reach them where they are, providing more choice, options, and transparency – all without sacrificing quality. Meeting this final criterion requires providing the care team with easy access to integrated data that offers a full picture view of the patient’s health.

As we move into 2015, we are working on a number of projects to improve the quality and convenience of care at Dignity Health including:

  • Increasing access by creating virtual urgent care centers or clinics where patients can reach a Dignity Health doctor on demand;
  • Providing patients with video visits as an alternative to traditional visits, given the interest of patients in meeting and interacting with their primary care doctors or specialists;
  • Monitoring patients via video so physicians and care managers can see their patients in their home environment. Physicians can also arm patients with home monitoring equipment once they are discharged from the hospital so they can track vitals, weight, oxygen levels, etc. without the patient ever having to step outside their front door.

Marrying virtual solutions with patient data helps create an environment that makes patients feel comfortable in their own space and reduces wait times and missing work, while still ensuring they feel their caregiver understands their environment and is making confident and personally relevant care decisions.  While some say technology creates a barrier, when implemented strategically, technology can actually make patients feel more connected, engaged, and satisfied with their care.

Davin Lundquist, MD is VP/CMIO of Dignity Health of San Francisco, CA. Lundquist graduated from the University of Southern California Keck School of Medicine in 1999. He specializes in Family Medicine and is affiliated with Saint Johns Regional Medical Center and Saint Johns Pleasant Valley Hospital. He speaks English and Spanish.


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The Healthcare Dinner Party

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WineIt may not be obvious, but the healthcare industry has been preparing for an enormous dinner party. Over the last several years, innovation vendors like AirStrip have been adding ingredients to our fridges and pantries based on numerous requests from customers. Metaphorically, this would be just about anything you can imagine that will transform clinical collaboration. At this point, companies can support a wide variety of different use cases across the continuum of care. However, the next phase is for healthcare industry to sit down at the table since it has been set up already for the big dinner party. The table and the settings are the EMRs, EHRs, medical device companies, among others. If we keep replacing them we will starve to death. Now, we need to spend more time figuring out what exactly the healthcare providers are trying to cook – getting to know their specific use cases by clinical service lines and working backwards with the ingredients that already exist, rather than waiting for food to appear magically at the table.

To do this, medical technology vendors must know their role in the process: to serve as a canvas for customer innovation. The goal is to use the strength of technology platforms that are created and have them run seamlessly in a way that provides clinicians the right data to address their patients’ needs. Each hospital and health system knows what they like and need better than anyone else – and working with them to design these systems accordingly will inspire innovation that can help other organizations. The vendor’s role is to take the technology that seems simple to the creators, and make it user-friendly and accessible in time-sensitive scenarios. This innovation could be things like bringing in contextual images, video, secure messaging, and other third-party components that are brought to customer’s APIs on top of a mobile platform all in context. Thus, physicians are able to work more efficiently, improve workflow and ultimately lead to better patient outcomes.

In the coming years, mobility adoption will be the fastest growing technology trend in healthcare, functioning primarily as a delivery mechanism for clinical decision support for healthcare providers. Physicians are clearly mobile professionals, and clinically relevant data needs to be provided to them wherever they are in order to improve the quality of care. Clinical decision support delivered via mobile devices will rely on a number of underlying technologies that are essential for clinical transformation. They include: big data analytics, real-time processing engines, tools focused on interoperability, care coordination, patient engagement and cloud computing.

Thus, medical technology companies need to assess what the hospitals are trying to ‘cook’ and create the technology to meet the needs of their use cases. Once these needs have been discovered, medical technology companies can whip up the perfect personalized recipe for each hospital or health system – one batch at a time.


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Creating a Friendly Environment for Adoption of Clinical Decision Support

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In recent years, our ability to stream large amounts of data in real-time has improved dramatically. This enhancement can transform how clinicians offer care by sourcing unprecedented opportunities for clinical decision support. However, the capability to process, store, and display data in and of itself does not transform care. Rather, it is how the clinicians adopt and apply decision support that will make all the difference to patients. However, the current environment must be altered to create a clinical decision support-friendly climate.

From a patient perspective, we must migrate away from automation of population-based models and toward a model that supports the individualization of care. From the clinician’s perspective, there is a thin line between enabling and burdening them with data. We need to find the right balance: empowering physicians to prescribe care using their training, experience, humanity, intelligence, and reason while giving them the technological support to catch and analyze what isn’t always obvious. If we are to make clinical decision support a reality, we must ensure that it is personalized, valuable, and adoptable.

There are a few things the industry needs to do to make this happen:

  1. Customize care: Each patient’s data, circumstances, responses, and care path will be unique. Clinical decision support is based on advanced analytics and calculated trends, but we must provide the patient-centered context to improve the accuracy of the final call. In the past, the industry has pushed for uniformity to the detriment of care and at the expense of patient individuality and physician autonomy. For example, clinical practice guidelines that do not allow for important patient-specific customizations are less than helpful. Guidelines tend to focus on populations and not people. We must not genericize the process of care. Our goal in providing more data and better care support should be to enable a patient-centric, unique plan upon which physicians can act immediately. This will require a convergence of clinical decision support, ready access to data, which has been transformed into actionable information, and alignment of customized medicine.
  1. Make it easy and put it in one place: As we move away from a one-size-fits-all approach, we also need to perfect interoperability and appropriate graphical user interfaces to improve ease of use, while getting the right information to the right person at the right time. In parallel, let’s also move away from the recent habit of “apping” our physicians to death. It isn’t efficient, and doctors aren’t learning to invest their effort into any particular application – they’re instead distracted and half-heartedly using a handful of various mobile tools. If physicians enjoyed true interoperability, data would be streaming through multiple processors to do digital background work for them and, in turn, providing patient-specific choices A, B and C. The key is giving clinicians options, rather than an answer, and in saving steps to make clinical workflow more efficient.
  1. Push for real reform: We must better align incentives for key stakeholders around innovation. Reform must move beyond its current focus on payment and access. We need fundamental changes in 1) physician training, behavior, and adoption; 2) incentives for the commercial life science industry; and 3) regulatory agency policies and practices.[i] Today we can leverage voluminous data, transform it into actionable information, and get it to a physician via a mobile device – essentially in near real-time. Getting physicians to embrace clinical decision support will require aligning incentives, embracing innovation, providing interoperability, and earning their trust.

Healthcare must be centered on the unique needs of individual patients. Providers need technology that powers customized, patient-centric clinical decision support. Expanding the scope of health care reform will foster an environment of innovation. Inside this new realm of creativity, physicians will actually be empowered and incentivized to actively leverage emerging technology to help transform care.

[i] Topol, E. 2012. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. Basic Books. New York, NY. ISBN-13: 9780465025503.


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Healthcare in South Africa – Two Systems, Common Challenges

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When it comes to mHealth, most industrialised nations such as the U.S. and Europe have a head start. Money for healthcare technology investments is available, the infrastructure is in place, and most of the population is already engaged in the healthcare system.

As a country of about 52 million people, South Africa shares many characteristics with its larger brethren. There is a mix of public and private healthcare providers and health insurance plans, physician shortages in key areas, and South Africa is beset by many of the same chronic diseases that industrialised countries face (cardiovascular and obesity-related diseases, diabetes, etc.).

But, the country also faces unique challenges.  HIV/AIDS and tuberculosis rates are high. Maternity and infant health issues affect large segments of the population.  The system is highly fragmented. These and other factors contribute to a life expectancy of only 58.5 years, twenty years shorter than in the US.

The South African healthcare system is really a tale of two systems. Basic primary care is provided free by the state, and the public health system serves about 80% of the population. The public sector is woefully underfunded, and care is less accessible and/or inadequate for that 80% of the population.

The South African government has embarked on major reforms to the system, including a universal National Health Insurance (NHI) programme. From its implementation beginning in 2012, however, the system will take 14 years to roll out.

For the remaining 20% of the South African population, healthcare is more accessible, better-funded and more effective. Middle- and upper-class citizens purchase supplemental care through various medical schemes (insurance plans), giving them access to better clinicians and advanced medical practices.

Public or private, there are a number of challenges the two systems share:

  • An over-reliance on paper records – When patients present at a medical facility, runners are dispatched to gather up paper records and bring them to the clinicians. Even when records have been digitized, there are few online systems for viewing and reviewing them.
  • Silos and lack of interoperability – Primary care are the gateways to the system, both public and private. Even more so than in the US, there are few common systems across primary care practices, so even where automation has taken place, these silos of information do not interoperate.
  • Lack of detailed clinical information – Although South Africa implemented ICD-10 beginning in 2005 (yes, 2005), the fragmentation of the systems has led to only simple, lowest-common-denominator information being available; sometimes only patient ID and diagnosis code are available to other clinicians. This blunts efforts at any sort of analytics that could improve quality or core measures. Real-time analytics, dashboards accessible through mobile devices, or remote notifications are all impossible without tools to cut across disparate systems.
  • Healthcare for mothers and babies – Maternal, infant and childhood mortality present a major health crisis throughout Africa. Prenatal care and monitoring in particular are inadequate, resulting in combinations of high maternal mortality, infant mortality, and post-natal complications. With many expectant mothers in far-flung areas of the country, this is a health crisis begging for innovative remote technology.
  • The need for secure health records and communication – Although not as stringent at HIPAA regulations in the US, and driven more by the medical schemes, security and privacy are essential to overcoming patients’ inherent distrust of technology, especially if data are to be shared through a variety of systems.

The South African healthcare system needs to undergo major change. “Business as usual” is unlikely to yield progress quickly enough. Innovative healthcare technology can provide an accelerator to improving conditions more quickly, with interoperable mHealth and telehealth playing a major role in that transformation.

Christopher Whitfield, CEO, founded Batswadi Pharmaceuticals in October 2005 as a specialist healthcare company focusing on four core business areas: pharmaceuticals, diagnostics, research and development, and consumer health. After jump-starting the company by leading a management buy-out of Eli Lilly’s insulin portfolio in South Africa, Christopher has quickly built Batswadi into a diversified company with significant potential. As the only black-empowered (majority-owned by historically disadvantaged South Africans) pharmaceutical company in South Africa, Batswadi is a rising star.


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Why 2015 is the Worst Time to be a Physician

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With the ONC’s recent release of their 10-year interoperability vision, it might seem like the industry is starting to make things easier for clinicians. In reality, 2015 is starting off to be one of the worst times ever to be a physician. Interoperability is a critical issue to support a transition from fee-for-service to value-based care. Physicians will eventually be reimbursed around their ability to impact clinical outcomes, so the need for clinically relevant information at their fingertips is mission critical.

Unfortunately, the ONC’s attempts at outlining an interoperable future make it clear that this vision is influenced by the same vendors that benefited from billions of dollars flowing to them from great federal programs like ONC’s Meaningful Use and will continue to benefit from a roadmap that delays the path to data and streamlined clinical workflows. Preventing caregivers from being overwhelmed by data is understandable, but it is certain that physicians need more data than the ONC is seeking. How can physicians be efficient and effective if they don’t get the information they so desperately need? How can we move them into a value-based care model without freeing the data needed to improve clinical outcomes? My colleague, AirStrip President Matt Patterson M.D., recently wrote a blog post around this, emphasizing how low the bar has been set in terms of standards.

The directive generating the most attention calls for “a common set of electronic clinical information…at the nationwide level by the end of 2017.” According to ONC, the common data set would consist of about 25 basic elements, such as patient demographics, immunization records and lab test results. It seems this vision was created to help ease the strains physicians face with the overwhelming amounts of data. However, the basic elements ONC is suggesting is a subset of the relevant data that is trapped in the source systems; it is not nearly enough information for physicians to make informed decisions effectively.

These limited requirements are also preventing the enforcement of standards and the creation of new ones that would encourage the healthcare industry to partner with vendors to improve the inner workings of their health systems. In order to understand clinically relevant data in near-real time, hospitals need about five to six times the amount of data ONC is proposing as a common data set for the initial phases. This additional contextual data is crucial in order to decide next steps and make patient decisions proactively and effectively. Some vendors today have the ability to expose this data but, for some reason, healthcare providers continue their acquisitions without strong interoperability requirements – as if they are obeying ONC’s roadmap and those that influenced it. In an era of consolidation and collaboration, this approach will lead to patient leakage for closed organizations.

The blocking of clinically relevant data from some legacy vendors and ONC’s relaxed requirements also stifle innovation, impeding new vendors that provide data analytics and visualization tools that are agnostic to the data source and result in a better user experience. This impediment forces providers to use their archaic visualization tools. This trend started with desktops and is quickly propagating to mobile devices. We are, in essence, mobilizing the mess and making physician’s lives more difficult. Not only are we limiting their access to data on a real-time basis, but we are now forcing them to open multiple mobile applications to view a patient record throughout the continuum of care. And to top it off, we will force them to improve population health management and care coordination, while aligning incentives around those goals.

Healthcare cannot mobilize or leverage innovations such as telemedicine without first being interoperable. Interoperability is the core of successful mobile healthcare, we cannot place all the blame on the ONC’s interoperability roadmap. It is time for healthcare providers, payers, pharma and technology vendors to join forces with the Federal Government and transform healthcare. As we gear up for another HIMSS, it appears interoperability will once again be a topic of discussion for the future. Maybe next year, it’ll finally be accepted as a standard and the topic will be centered around the patient who in the end should own their data.


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Telehealth Brings Non-Stress Tests to the Home

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Non-stress tests (NSTs) are the current standard of care for monitoring high-risk pregnancies. Intended to reduce the risk of stillbirths, these tests are for those who have one or more risk factors, whether they be maternal, fetal or obstetric complications.

Currently, these tests can be very time-consuming for patients. NSTs involve attaching the mother to fetal and contraction monitors to watch the fetal heart rate tracing and uterine activity. However, many rural and remote areas don’t have ready access to NSTs. Consequently, mothers sometimes travel up to several hours each way to get to our facility for their NST appointments once or twice a week. Once they arrive, there’s the usual wait time, the 30-60 minute testing process, plus an additional wait time for the test to be interpreted by a staff member and a clinician. These appointments, on top of any additional prenatal visits the mothers have scheduled, can therefore add up to a considerable amount of time, even for patients who live nearby.

Telehealth and at-home NSTs may be able to transform this process for our patients. We are now conducting a pilot study that provides patients the technology to conduct at-home NSTs. Mothers in their third trimester of pregnancy who are on a schedule of twice-weekly NSTs will have one test on-site and one test at home every week. These patients will be thoroughly trained on how to use the at-home NST device, and will conduct a practice NST in the presence of an advanced practice clinician before sending them home to do the testing. After that, patients will conduct the home NSTs themselves as part of a ‘virtual’ appointment, with an advanced practice clinician carefully monitoring the test results.

By conducting NST tests at home, we hope the following might be achieved:

  • Improved Patient Satisfaction: A telehealth strategy for NSTs will reduce the number of required on-site appointments. This strategy also means more flexibility, comfort and convenience for our patients.
  • Enhanced Efficiency and Capacity: Facilities have a limited amount of space and personnel to conduct NSTs. For example, the University of Utah Health Care has four chairs dedicated to these tests, so appointments need to be scheduled accordingly. By conducting NSTs at home, we can engage with more patients, increasing our flexibility to accommodate those who need NSTs. While there still needs to be careful supervision by trained clinicians, this process may greatly improve our efficiency and capacity for NST testing.
  • Cost Effectiveness: Performing an NST can cost several hundred dollars, and part of that fee is for the use of the facility. The clinician interpretation portion of the billing is always going to be the same – someone always has to look at the results and render an opinion – but by conducting a number of these tests off-site, there is an opportunity for significant cost savings for payors. Home NSTs may also mean cost savings for the hospital, since efficiency and capacity are expected to improve.  Patients will also likely save money related to travel, missed work and childcare expenses.

Healthcare systems are becoming increasingly interested in implementing innovative care strategies in order to improve the quality of health care, reduce cost and improve patient satisfaction – in other words, create value. Within obstetrics, home NSTs show promise for helping to achieve these aims.  Our research will consider whether this technology could develop into a viable NST option for health care systems across the nation.

 

Erin Clark, MD has been an Assistant Professor of Obstetrics and Gynecology at the University of Utah Health Sciences Center since she completed her Maternal-Fetal Medicine Fellowship at the University of Utah in 2009. She is board certified in Obstetrics and Gynecology, as well as the subspecialty of Maternal-Fetal Medicine. She initiated the Preterm Birth Prevention Clinic for the Utah Department of Health in 2010. Dr. Clark’s current research includes a grant from the NICHD to look at markers of developmental delay and cerebral palsy. Other interests include pelvic floor dysfunction related to childbirth and preterm labor.


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Finding Balance in Chaos

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hospital-1822460_1920The role of a nurse is a complex one. Not only is this individual responsible for the physical bedside care of multiple patients, but may also be called upon to offer emotional support for patients and their families. While this is an absolute honor and a privilege, it can also be emotionally draining and lead to burnout syndrome or compassion fatigue. In order to ensure that patients receive the highest quality care, we must make sure that nurses have support for their own emotional well-being.

Seek Closure

One of the most difficult situations a nurse can experience is losing a patient. No matter the situation or how long the patient was under a nurse’s care, it is hard to ignore the fear that something more could have been done. With the introduction of technology and a digital record of a patient’s stay, care teams now have objective data that can be reviewed and assessed after an incident. Simply knowing what exactly happened can relieve an element of stress, because the unknown is often more terrifying.

By reviewing these records as a team, nurses also benefit from an objective, clinical process that removes the emotional chaos. Instead of wondering whether it was an isolated event that caused the patient to deteriorate or a symptom that had been trending for days, nurses can find emotional support from leadership and peers. By using these sessions as learning experiences and refusing to point blame at any one individual, these reviews can foster positive physician-nurse collaboration, building a foundation of trust for an environment where both parties can confidently work side by side.

Lean on Resources

While nurses must remain focused on caring for their patients, the families and loved ones of these patients often need support and information as well. This is particularly important for high-stress wards like the ICU and pediatrics. By identifying and leveraging resources within the hospital – whether a social worker, chaplain, or the resident psychologist – a nurse can ensure that the family has the resources they need and are treated with the respect they deserve.

Ask for Help

Nurses can’t be afraid to ask for help. One of the most beneficial things a nurse can do is identify a mentor that can offer both emotional and clinical support. Having someone to turn to in times of duress or confusion can make a significant difference in a nurse’s experience – as well as a patient’s. As this mentor is usually someone who can recognize emotional fatigue, avoiding burnout before it happens helps ensure everyone’s health and care remains the top priority.

Another resource: other nurses! Forming a peer group within the hospital that meets on a regular basis creates a forum to share experiences and stressors. Open conversation can ease the burden of feeling alone and provides a safe space within the context of a group who would understand.

With the right resources and approach, finding and maintaining a balance between investing in patients’ well-being and preserving a nurse’s own health can be much less daunting. Remembering that a hospital is a community – and everyone is working toward the same goal – can make a significant difference in a nurse’s life.

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