The New Economy

During my visit to San Diego for the NSCA leadership conference Economist Lee McPheters spoke about the economic changes and challenges facing our nation. While the economy seems a daunting – I think that the needed productivity changes are also a huge opportunities for those of us in process redesign and we just need to find ways monetize the work associated. The American worker has been asked to increase their productivity – put in the extra hours – in hopes to help their company make it through the rough waters. The challenge is we can only work so many hours – we can only work at high capacity for so long before it requires an innovation change.

The interesting change is that while businesses have pushed their employees to be “lean” and move faster and do more with less – the American consumer has become more demanding. They expect more, because they are spending less. The American consumer is adopting the Ramsean principals of if you don’t need it don’t buy it - if you don't have the cash then don't buy it.   They are also spending their capital in a more focused manner with a thought process of  you should be treated like a customer instead of a consumer and the idea of disposable society should go by the wayside.

So what does all of this mean for healthcare? It means that the patients – who are customers – should be treated as such and that their demands will become more and more extensive.

Let’s Dream Weave?

If my grandma eats breakfast every morning at 6:30am when she is at home, then when she is in the hospital for hip replacement shouldn’t the hospital know when Grandma would like to eat breakfast? Tools like A-Frame Digital and Parental Health’s Misty can feed into her “record” and begin to create a model of how she chooses to be cared for when she is not in her home. The more data we can drive from the home to the health record the more we can allow our parents to age in place. 
The scenarios of how we function in the home should model how we are cared for in the hospital. The concept of a Patient Communications Platform should encompass more than just request from point A to point B – it should encompass consumer data modeling that preemptively leads to care.

If I document my life in Facebook and am comfortable sharing it with 400+ of my closest friends wouldn’t I be comfortable with sharing my comfort models with the hospital? If I document my food and exercise in My Fitness Pal (ap on the iphone) then why wouldn’t I share my nureotic eating habits with the place that is supposed to heal my ailments? (What if my ailments are caused by my addiction to Latte’s?)

These models allow us to improve patient care. At Sphere3 we use Performance IndiCares™ which are items relating to the behavior and performance of Caregivers and Patient IndiCares™ which are items relating to the behaviors of the patient. We tie the information together to create Risk Models or Risk IndiCares™ clearly finding paths to reduce risk and improve performance. All of these things lead to our three core values Patient Satisfaction, Caregiver Satisfaction, and Safety.

Health IT companies should feel challenged. If the farthest horizon you are looking at is within the walls of the hospital, then you are going to miss the boat.

Patient As a Consumer

Coca-Cola is test marketing a product called the “Free Style”. It’s a box (isn’t everything) that allows the customer to select their Coke product, and even Mix n Match the flavors. If it were just a pop dispenser it wouldn’t be so interesting – what IS interesting is that the box is daily providing information back to head quarters about which products were selected, how specialty blends were selected, etc…in essence a direct information feedback loop of what people want.

Every Hospital has a “Free Style”- it’s required by code and it’s providing multitudes of data that reveal how a patient wants to be cared for on a daily, hourly, even minute by minute basis. The Nurse Call System is alive with information that indicates how a patient’s stay is going. Interestingly, this immediate patient feedback tool is often dismissed as something required by code. It is more about safety then about information. While many nurse call systems are reaching beyond the safety realm and designing abilities for requests – the data is inefficiently and ineffectively managed by the hospital.  HP made a great point in their focus group the Patient must be viewed as a consumer and we must cater to their needs.  The way to do this is to understand their communicated requests.

It’s got to be seen as more than just a safety tool – it’s got to be seen as a tool that lets the patient tell their story.

Let me dream weave with you for a while…… If a patient is consistently asking for a blanket could we automate the heating system to kick on and raise the temperature?  Yes, if we knew they were asking specifically for a blanket.
If a patient is consistently asking for water or ice chips, could a model be created to preemptively provide them with a glass of water before they ask? OR is that indication of something occurring physically that needs to be checked by a doctor? OR for you safety nuts – what do you do a little while after you drink 6 glasses of water that could cause a fall? OR could the information automatically be cross referenced with the EMR data and could IBM’s Watson decide a lab needs to be ordered?

I know that sounds space age but the information is all there – it just takes looking at it, creating a model, and well…the hard part getting everyone to talk together in a common language.

Just to get you thinking – why isn’t the nurse call system called a nurse call system – are they stewardesses or are they clinicians? It needs to be labeled the patient communication platform and IF it is a patient communication platform……why does it only reside within the hospital?

The EMR Limitation

Have you ever done weight watchers? I have and it was fun for a while, but then you start to figure out ways around the rules, the math associated witht he "points", and the limiting factors associated with losing weight – it becomes not fun. For example, why is it motivating to lose my daily points allotment if I lose weight? Isn’t that a punishment? Think about it last week I could have a cookie because I was heavier, but this week after having lost 3 lbs I changed categories (which means your allotted points decrease) means I lost the extra points needed to partake of my favorite treat. 

The other limitation of weight watchers (and frankly any diet) is it’s based on self-reporting. Similar to an EMR if you report incorrectly and cause an error there are consequences – in my case think Bridget Jones – in the second movie.

Yes, Yes, there is an analogy here to Health IT – EMR is dependent on the physical documentation of a clinician, doctor, or other caregiver. There are advances being made to reduce errors such as the automated physiological data capture. There are methodologies by use of Pixis (the Kleenex of the medication world) and other like systems to assist with managing the medication transfer to the unit and barcodes to assist with reducing medication error. There are even RTLS tools that can be used to identify caregiver entry and exit and time frames.  All good things.
There are all sorts of devices, software systems, and technology being created to make things bigger better faster cheaper, but where is the patient in all of this? EMR is a self-reporting tool that allows clinical individuals to document their interactions with patients. But, how are we documenting the Patients interactions with Caregivers.

Why are we painting a picture of the patients stay based on the hospital’s perspective?

What do the patients movements, actions, and requests say about their stay?

Why are we judging a fall risk based on a questionnaire and physical observations?

We are judging caregiver satisfaction by surveys and turnover rate?

Why are we using a survey that’s provided after the patients stay to assess their satisfaction?

What if there is more……what if there were a way to see answers looking at data that is readily available? There is so much information available that provides a clear picture.

The next frontier is not the EMR – the EMR is the current frontier – the next frontier is the patient – the next frontier is the information that the patient is providing to the hospital - physiologically and physically.

Hospital Value-Based Purchasing Program (VBP)

I am pleased to welcome my first guest blogger.  Rebecca Mackinnon has been working with Sphere3 for several months.  She successfully built a HIT company called Beyond Now Technologies which is now part of Cerner's portfolio.  A brilliant woman who offers great insight and perspective.

Hospital Value-Based Purchasing Programs

We've been told for years that hospitals would be judged and paid upon performance, and now it looks like the time has arrived!

The Hospital Value-Based Purchasing Program is the first concrete step with defined timelines of performance measure for the purposes of calculating premium to the DRG. The interesting detail in the labyrinth of language: there will be a baseline reduction in the DRG and then VBP calculation will be applied on the new DRG base.

Unwind and interpret...you will be penalized if you can’t prove minimum quality performance.

The CMS proposal: 17 clinical processes of care and 8 measures (from HCAHPS) with a currently proposed ticking clock beginning from 7/1/2011 through 3/31/2012 to adjust the FY 2013 DRG payments. If I do the counting on my left hand correctly, five months before the clock begins ticking.

So here is what I know. Regardless of what any hospital wants to purport, some of the very expensive and very avoidable clinical measures are not being managed.

Here are the basic questions every hospital CEO should be using to challenge the CMO and CNO:

What is our Falls Ratio (falls/1000 patient days)? How are we assessing the Root Cause?  Is the information being used in and educational and reforming way to improve for the future?

What is our rounding procedure and how often is it adhered to on the Unit level?

What is the actual response time to a patient request? Response time to pain? Response time to toileting?

What is our hospital noise coefficient?

What are our alarm frequency measures and response times?

Each of these is the most basic unit level measure of performance and ties directly to the ability to improve performance in the FY 2013

A very insightful CEO of an inner city health system spoke to a small group in the recent weeks. His best advice to his audience, “you have to get into the bowels of your organization, you have to know what’s happening and be able to create a clear line of sight from staff activities to mission critical performance”

Sphere3 has been expecting this for two years. This month, we will debut of a comprehensive option for managing quality.

Sphere 3’s business intelligence software endeavor combined with our consulting team who are experienced in clinical process, Nurse Call and other alarming technology design is now more important than ever.

When the Beep is a Heart......

Last week a dear friend fell on the ice, hit his head, and had a stroke. He was taken from the rural critical access facility to a larger facility in the “city”. The family (most of who were from the city) had so many trials gaining information necessary to help care for their father, and I was struck by something – we have gallons of information available about patients now and the only people who get to see it are the “educated” ones. One day he was doing better and the next he was in ICU and the family was told to “prepare”.

It’s always hard for me to go to a hospital – it’s kind of like eating at a restaurant when you have been in food service. When I walked into ICU and looked at his monitors it was so striking – We have been in heavy R&D lately developing new metrics, and producing our new software program. I stood in that ICU, stroking the beard of my friend, and thinking it’s not just math. It wasn’t just a number that needed to be processed for automation or documentation – it was his heart, it was his life. This man, who the night before his fall had called to sing happy birthday to my son, was hooked up to all of these machines.

Do you ever feel like you are just looking at a page full of numbers when you are analyzing the work your do? “Alert quantities” take on such a different meaning when you are staring into the face of friend.

How do we make it all about him – the patient? How do we make it meaningful to this man and his family? They were so scared. They didn’t understand and by the time I arrived at the hospital – they didn’t trust the staff because they weren’t being communicated with clearly. As I talked with them there were a few things that stood out to me that every family should know going into a hospital.

• Have an advocate with the patient, and keep track of “vital” information. When the nursing staff is collecting information, ask what they are doing and be engaged in the answer. It may not make sense on day one but it will by day 2 or 3 it will start to make sense. If it still doesn’t make sense ask more questions, or see if the hospital has a Patient Advocate.
• For example, if your family member has a fever – ask why – ask what tests are being done to figure out why – ask what his temperature should be.
• Use the internet to understand the condition – but remember the internet is not always right, and it can’t see your family member.
• Know your caregivers by name – the Nurse is the one who gives medicine – the Care Tech is the one that brings ice chips, helps the patient to the bathroom, and does the leg work. The Nurse is probably tending to 5-6 people during her shift and the Care Tech may have as many as 12. If you have a problem the person in charge of the Nurses is the Charge Nurse.  Get to know the Unit Secretary too – the person at the center desk that answers the phone - they are often air traffic control for the unit.
• Use a life line - Phone a friend. When you are in the thick of it, and emotions are high you may not be thinking clearly. Call someone you are close to and download – they may have different perspective and be able to help you refocus.
• Take a break. If you are the only person from your family available to sit with the patient – know that the care staff will be there when you are not. Just let them know you are going to the cafeteria or getting some dinner. When BFB was in the hospital the hardest thing I had to do was leave for an hour – but my Nurse (who was wonderful) insisted so that I could relax and refocus.
• Pray Continually – this one is my personal advice, but it works. Even if you don’t believe -sometimes you just need a release and no person around.

As we move into an era of “Smart Phones” let’s not create a Soulless environment where we have so much data and we forget that the man in ICU is someone’s Dad, Grandpa, and friend. Technology must be an enabling medium – it must be something that allows a caregiver to care – not limit their ability to engage. Every click is a moment they aren’t engaged with a family – every alarm is a moment they aren’t focused on a patient.
How do we create less “technology drain” and create more “patient engagement”? We all need to make sure that our focus is creating an environment that is conducive to healing, or if the family is saying good bye create an environment of peace.