In part 2 of this series we talked about the need for data-driven clinical tools that better address the paradoxical realities of clinical practice, such as the prevention of adverse drug events (ADEs). Balancing this tension is paramount to achieving optimal patient outcomes. In part 3, we will link the health care team’s capacity to adjust to the situational demands of a rapidly changing clinical work environment to value-based care and the return on our healthcare investment.
In response to growing regulatory pressure, there has been a rapid and continuous introduction of new ideas, processes and information technologies. Sweeping advances in new treatments and specialties has spawned layers of care, multiple patient touch points and volumes of fragmented data. As a result, the fine line defining what constitutes high-risk care is blurring. The impact at the point of care is palpable. Julie Gunther, MD (2018, May 15), in a recent blog for KevinMD.com, writes:
“I left my role as an employed physician in the traditional insurance-based fee-for-service structure because I spent 80 or more hours a week typing, collecting data, coding, answering to documentation requirements and saying, “I’m sorry.” “I’m sorry I’m late.” “I’m sorry we can’t address this now.” “I’m sorry they couldn’t get you in.” “I’m sorry that other doctor made you feel like less than you are.” “I’m sorry!” Over and over and over again. Less than 40 percent of a traditional physician’s day is spent in direct clinical care. The rest is spent, often at night, on weekends and while on vacation … typing. Documenting. Recording what happened instead of being present while it is happening.”
Despite our digital capabilities, clinicians and patients alike are frustrated by the slow progress to provide up-to-date technology tools that support a wide range of treatments, services and shared decision-making. Clinicians can feel the shifting sand under their feet as the ever-changing context of care challenges our approach to clinical decision-making.
There is a way forward. Leverage points do exist within a complex system. A small shift in one thing can produce big changes system-wide. As a starting point, we need to see every patient encounter, from the primary care provider to the cardiologist, as part of one high-risk system. In an IOM report, William W. Stead describes a shift away from expert-based practice, built around the extensive knowledge and experience of a sole physician, as “inevitable given the increasing gap between human cognitive capacity and the number of facts to consider in a single clinical decision.” Stead envisions a shift toward systems-supported practice where, “people provide compassion, pattern recognition, and judgment,” and “teams of people, well-defined processes, and IT tools work in concert to produce the desired result consistently (IOM, 2008; p. 18).” We still need experts but our growing impotence stems from the lack of a systems approach.
So how can we achieve consistent performance amidst the rate of change, address a number of clinical problems, and consider the variability of individuals and conditions? The difference is in how practices translate evidence into action.
In a learning organization, the rate at which organizations learn becomes the only sustainable source of competitive advantage (Senge, 1990). The point of care team is a vital source of organizational learning and innovation. The operational tempo of knowledge and research flowing in the same direction has resulted in the untapped knowledge acquired by point of care clinicians while doing their jobs. Optimal information exchange and learning is bi-directional, but even more pressing is the rate of learning which will ultimately determine our viability.
Well-connected clinicians guided by meaningful and actionable information, and system-oriented clinical leaders are critical links to value in the changing and turbulent context of care. Clinical teams must be wired to learn and innovate. Networking with innovative work groups and aligning with agile developers who listen and understand the intersecting needs of patients and clinicians, will allow us to move the needle closer to ensuring the “right” health care for each person. We will talk more about networking and leading from the front lines of care in the next blog.
Point of care clinicians do not have to be helplessly caught up in the turbulent storm of change. The clinical team is part of a larger system of care and can no longer exist in isolation. CMS has been overhauling and streamlining its payment programs to promote value and prioritize outcomes that matter to patients. With the mandate on adverse drug event prevention, leveraging high impact activities becomes critical both from a quality and reimbursement perspective. Implementing electronic decision support is a critical part of these incentive programs to include additional bonus incentive points for implementing efficient tools and resources that focus on risk management, population health features, critical touchpoints and care transitions. Advances in treatment are changing quickly and there is a need to develop tools that can deliver dashboard analytics matching patient data with disease specific information at that point of care, including elements from guidelines, quality metrics, comparative effectiveness data, and population indicators. PCDS strongly believes in and supports real-time learning and evidence-based action embedded in the clinical workflow that engages clinicians in making real, system-level changes that lead to measurable improvements in care.
The collision of technology, complexity and social change is significantly changing how we communicate, relate, deliver care and conduct business. it is important to reflect on how emerging challenges will shape how care is delivered safely and compassionately. We cannot afford quick-fix approaches. We need to leverage solutions that foster connection and invest in agile technology that quickly adapts to new treatment options, provides actionable information and analytics, distills volumes of research and recommendations, and embeds real-time learning in the clinical workflow. What are your clinical priorities and how do you see technology enabling learning and innovation at the point of care?
Gelatt, H. (1993). Future sense: Creating the future. The Futurist 27(5)
Gunther, JK. (2018, May 15). KevinMD.com https://www.kevinmd.com/blog/2018/05/physicians-let-us-rise-let-us-lead.html
Institute of Medicine (IOM). (2008). Evidence-based medicine and the changing nature of health care: Meeting summary (IOM roundtable on evidence-based medicine). Washington, D.C.: The National Academies Press.
Senge, PM. (1990). The fifth discipline: The art and practice of the learning organization. New York: Currency/Doubleday.