Case Study “Are Technology Barriers Affecting Best Practices and Quality of Care?”

Are Technology Barriers Affecting Best Practices and Quality of Care?

T (Teo) Forcht Dagi MD, MPH, DMedSc, FAANS, FACS, FCCM

HLM Venture Partners

Harvard Medical School & Queen’s University Belfast

Disclosures

Partner, HLM Venture Partners, Boston

Chief medical officer, Aventura, Inc., Denver

No compensation has been offered or received in conjunction with this presentation

02/04/2012 2 ©T Forcht Dagi 2012, all rights reserved

Technology Device or Set of Functional Tools

• Tools to leverage, extend and improve upon human capacities – Strength – Accuracy – Communication – Vision and the other senses – Memory – Calculation – Speed and reaction time – Reaction sequences – Hazardous or otherwise impossible conditions – Endurance


Technology More Broadly

• Tools to overcome boredom and routine and mimic human capacity

– Automation, including process automation

– Robotics

• Tools to improve precision

• Tools that combine capabilities and processes in complex ways and for purposes not otherwise possible

02/04/2012 ©T Forcht Dagi 2012, all rights reserved 4

Limitations of Technology

• Non-derivative novelty, ingenuity and creativity

• True invention

• Discretion

• Autonomous “leaps”

• Insight

• Emotion

• Kindness and personalization

• Humor


Technology as Barrier

• Instruction s sets inadequate for purpose

• Required sequences limit utility and versatility

• Complexity of access

• Access time

• Process or data corruption and loss

• Back-up systems

• Alternative work processes

• Uncoordinated components


Best Practices in Medicine Traditional

• History, examination, diagnosis, prognosis, treatment, follow-up, discharge

• Record for purposes of documentation and contribution to knowledge, left to the discretion of physician

• Document for billing purposes

• Personal engagement (doctor-patient-family)

• Good medicine highly dependent on physician

• Trust


Best Practices in Medicine Current

• Diagnostic and therapeutic process not substantially different • Assisted by decision support systems • Record also for purposes of compliance and oversight, so

formalized • Document for reimbursement, but also process and outcome • Difficult to satisfy requirements without EHR • Personal engagement emphasized less than system engagement • Good medicine redefined to include prevention, but also matters of

interest for economic and population • Individual relationships supplanted? • Trust in “system” rather than judgment of physician? • Who is ultimately accountable?


New “Best Practice” Icons

• Reduce variance

• Reduce error

• Decision support

• Track physician behavior

• Engage and track patient behavior


Obvious System Advantages and Support of Quality Measures

• Masses of data and data analytics, including predictive modeling

• System-wide resource allocation • Contributors to disease and illness • Confluence of the set and the statistic • Genomic and epigenetic factors • Enriched populations and other improvements in clinical

trials • Meaningful observational studies • Trend tracking • Synoptic medical records and patient portal • Consumer engagement


Efforts Needed to Retain Humanity

• Medicine should still be about patients

• Technology of tremendous value but

– Easy to look at screen instead of patient

– Easy to become caught up in protocolized work flow instead of remaining responsive to patient

– Easy to define good medicine in terms of population outcomes rather than individual outcomes

– Easy to anonymize care


Technology Design

• The problem of technological positivism

• The problem of work flow persistence

• Can ignore or alienate clinicians

• Elegant technology solutions sometimes fail in the context of real world complexity

• The medical world is slow to change

• Legacy systems will be around for some time

• Physicians seek technological invisibility


The Technology Challenge I

1. Time required to enter, access and sign out of system 2. Ergonomics of data entry, information access, retrieval, and

management 3. How are data and system corrections managed? 4. How are upgrades and changes managed? 5. How invasive are decision support systems? Are they time-efficient,

current, helpful and flexible? 6. Does the system provide for data support systems (genomics) as well as

decision support systems (diagnosis, CPOE)? 7. Is it possible to get a “blink” of data? 8. Is it possible to access or print out the specific information needed (as

opposed to the entire record) 9. Where are access points and are they sufficient? 10. Is all information available in appropriate (diagnostic, pictorial, graphic)

form?


The Technology Challenge II

11. Is all information required accessible at the same station? 12. How to deal with interoperability of hospital facing units (pre-

hospital, ER, ICU, OR, ward, case management) both within and across institutions (merged, affiliated or independent

13. How to deal with interoperability of outpatient systems? 14. Are all legacy systems compatible? 15. When and where should information be available in print form? 16. Are security routines automated? 17. How and when to override protocols? 18. Can the system contend with all therapeutic, administrative and

teaching functions required and undertaken in the institution? 19. Is the system context sensitive to clinicians and patients? 20. How to practice when the system goes down?


Is Technology a Barrier to Best Practices and Quality of Care?

• Double edged sword

• Technology can help optimize care

• Technology can be a barrier to care

• Technology is a tool to be deployed artfully and intelligently

• Technology should be developed in the service of work flow

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Summary

• Technology can both enable and impair best medical practices

• Good design must take into account the use context

• Useful technologies follow and do not attempt to change clinician work flows

• Because not all clinicians have the same work flow pattern, one size does not fit all

• Quality of care must remain patient centered rather than system centered

• Technological positivism does not work


Case Study “Are Technology Barriers Affecting Best Practices and Quality of Care?”

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