Part 1 in a 4 Part Series. Read the Introduction here
In part one we will explore knowledge management tools that will elevate your practice, facilitate safe, evidence-based, data-driven decision making, and promote the point of care as a vital source of learning, innovation, and leadership.
It has been estimated that by 2020 the average person will create an entire gigabyte of health data every day (McKinsey, 2017). As a clinician, how do you make sense of all that information? What are the implications as patients transverse across large, complex and dispersed organizations and systems of care? Clinicians want to be equipped to efficiently, effectively and safely manage the health care needs of patients while staying engaged to improve our system of care. Learning and contributing to health care advancement is in our DNA. I want to talk about how point of care clinicians can insert their DNA into their systems of care as a driver of learning and innovation. We will take a look at examples of cutting-edge ways to engage your practice and your patients.
A few decades ago, Tom Davenport (Davenport, 1994) wrote on the importance of a human-centered approach to information management (how people use information) in contrast to the standard IT view (how people use machines). He profoundly speaks to the importance of knowledge management as, “the process of capturing, distributing, and effectively using knowledge.” Health IT did not consider the patient-centered approach to information management when structuring the current IT infrastructure and we have been feeling the pain points of our data silos and disconnect with patients. However, the tide is turning and opportunities are emerging as CMS implements the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) to incentivize movement toward patient-centered data sharing across the continuum of care in a dramatic shift from meaningful use to promoting interoperability.
How can we change if we are not given the opportunity to learn? As lawmakers set the tone, CMS implements the payment models, and organizations scramble to get paid, clinicians need to prepare for the deluge of data and push their healthcare organizations to leverage high-impact patient-centered health information tools. Let’s apply the Pareto principle (Bunkley, 2008), also known as the 80/20 rule or the law of the vital few. Consider that the minority or 20% of the higher risk patients we care for account for 80% of the workload and cost of care.
Tools need to help the healthcare team, to include patients, make sense of the best evidence and treatments, and to understand what is working and what is not working -starting with our most vulnerable populations. Brandon Purcell, a senior analyst and analytics specialist, recently stated in Healthcare IT News (Siwicki, 2018), “Healthcare providers should look to adopt solutions that have been trained in their specific use case and offer the ability to further customize models through the process of 'transfer learning.’” There are certainly solutions available and it is not uncommon for a clinician to have multiple specialty apps open on their desktop and phone like UpToDate®, Epocrates® or MediCalc®. We are seeing some transfer of knowledge, but what is the breadth and scope of learning across the healthcare continuum? How does efficiency impact effectiveness?
There is a new breed of disease management tools emerging that can help. Application Programming Interfaces (APIs) are becoming a powerful way for software developers inside and outside the healthcare industry to join forces with healthcare organizations to implement specialized tools to manage population health, patient risk factors, and deliver systematic and coordinated care for high risk patient populations such as anticoagulation (AC) management. There are three great (free) apps to check out by clicking on the links provided (MAPPP, MAQI2, Anticoag Evaluator). MAPPP from IPRO* focuses on the management of AC during the peri-procedural period. The ACC* Anticoag Evaluator will calculate the need for oral AC while comparing the risks/benefits of the various treatments side by side. The University of Michigan MAQI2 AC Toolkit has similar capabilities and integrates risk calculators with management of warfarin. However, many of the apps in development have yet to include all of the key components required to manage a specific disease state and the clinician would have to open multiple apps to deliver a comprehensive AC patient plan. For example, one app may incorporate a warfarin dosing nomogram but exclude the newer anticoagulants (NOACs* or DOACs*). Other apps may specialize in episodic medication disruption such as periprocedural medication management for patients on ACs but lack longitudinal quality measures such as TTR*, or the ability to seamlessly integrate data bi-directionally with multiple EHRs.
Knowledge management tools connect us in meaningful ways. The EHR may be the “golden record” but the point of care must be the “golden source” of learning and innovation. Sorena Nadaf, chief informatics officer and director of data science at City of Hope, said, "It's not technology that's going to drive the changes. It's the way we apply and learn from it that will allow us to grow (Miliard, 2018).” I believe we can adapt and chart a course toward patient-centered information technology. Complimentary technology such as disease management apps utilizing APIs may bridge that gap and help us make sense of the data. There are examples of “outsiders” collaborating in the healthcare industry to solve these critical pain points. Point of Care Decision Support is an example of a complimentary EHR technology that is applying industry knowledge of APIs to deliver comprehensive disease management across the care continuum as a seamless part of the patient encounter.
We are getting smarter. Just having robust, reliable and efficient tools at our fingertips and at the point of care is a huge step in the right direction. Yet, we can expect better. Clinicians need tools and feedback systems at the point of care to help us capture and manage the knowledge and insights we gain. Clinicians have opportunities to promote innovative ways to manage new knowledge and gain competitive insights that elevate clinical practice as the golden source of learning and innovation. I encourage you to talk to your Chief Officers and advocate for point of care technology tools that can change your practice. What challenges have you faced when looking to health IT solutions currently available?
*IPRO: A national organization providing a full spectrum of healthcare assessment and improvement services that foster more efficient use of resources and enhance healthcare quality to achieve better patient outcomes.
*ACC: American College of Cardiology
*NOACs: Novel Oral Anticoagulants or Non-vitamin K Oral Anticoagulants
*DOACs: Direct Oral Anticoagulants
*TTR: Time in Therapeutic Range
Bunkley, 2008. https://www.nytimes.com/2008/03/03/business/03juran.html