University of Houston Clear Lake

Pam Potter

Orthopedic outpatient visits are continually redefined and challenged by market forces, regulation, insurance requirements, patient expectations and the associated technologies necessary to provide access, deliver care, coordinate and communicate treatment, collect, and appropriately record the health status of a patient. We agree there is no perfect delivery system for the health care continuum or a proven transformational approach on the horizon. We do see within the industry a vast array of improvements and innovation in each of the above sectors. Many of these improvements are dynamic and helpful but often fragmented, costly and transactional. They create new workflows along with additional barriers and stresses. From a personnel or human resource perspective they present major hurdles for organizational CIOs, as the organizations in which they work have sometime competing burdens, motivations and regulations under which they operate. Not understanding the emotive impact on the providers has unintended consequences as each of these transactions try to service various needs.

Patient access is dramatically related to the number of providers servicing the population. In urban, competitive environments, patient access transcends into marketing, having your organizations technology at the patient’s fingertips when they decide to seek care. Portals or marketing websites connect patients to appointment schedules, along with wait times or same day appointments. This transactional encounter, while valuable to the patient experience, fails to factor in the need for referrals, insurance network status or ensuring the care is appropriate and in the right setting with the right doctor. Open scheduling and direct patient access requires corresponding workflow changes to adapt, verify and support time sensitive transaction. Telemedicine offers care to patients in a rural setting or seeking care from a limited subspecialist. While offering patient convenience, reduced time off work or less traveling, telemedicine also requires patients and providers to adapt to an unfamiliar communication setting.

“This future involves substantial changes in technology, requiring priority decisions that impact our communications, providers, processes and reimbursements”

Standard care delivery begins by sitting down in front of a computer. Staff compiles and obtains clinical information, providers view other providers notes and results. The provider then enters the room and talks about the findings, concerns and listens to what the patient is saying. During this dialogue, the provider then must either turn their back on the patient, disengage from the conversation or leave the room to access the computerized chart. Here the provider looks for additional information, reviews diagnostic studies or starts the ordering, billing and documentation process which is not necessarily completed before the next patient visit. Patients routinely complain about doctors turning their back on them, describing how it makes them feel disrespected or that they are competing with the computer for their doctor’s attention. In a 2018 Medscape report, there were two malpractice claims for which EHRs were either the cause or (more likely) a contributing factor between 2007 and 2010. From 2011 through the end of 2016, there were 161. How telemedicine will impact the patient communication experience has yet to be determined.

Continual distractions in the care delivery process are difficult for our providers. Substantial portions of the documentation are not focused on the medical care, but to satisfy requests for additional data. Security access and controls don’t encourage cross trained staff positions. Where workflows are not addressed or fully understood, it creates workarounds or shortcuts, which may not meet the downstream needs of the organization, possibly putting at risk regulated security controls, producing inaccurate documentation, reimbursement losses, additional peer reviews or lacking support for medical necessity. This all takes its toll. Another 2018 Medscape report reported 56 percent of physicians stated they had too many bureaucratic tasks such as charting and paperwork, 39 percent noted having to spend too many hours at work and 24 percent said that increasing computerization of the practice, such as electronic health records, was contributing to their burnout. By specialty, 34 percent of orthopedic physicians say they are burned out.

We face value-based care with a focus on enhancing the patient experience and reducing cost to improve our community’s health. Consider what medicine is, which is many times, changing patient’s behaviors or adjusting them to new normals throughout their life journey. While there is a great appreciation of the data analytics in steering us towards the right patient care at the right time. The disruption of technology on this very human process is sometimes undervalued, when prioritized opposite of regulation, reimbursements or other organizational demands. Prioritizing the need to improve the work life balance of our providers is crucial, as the burned-out provider is associated with lower patient satisfaction and a reduction in positive outcomes.

Many envision a future, with an interactive system capable of documenting the patient encounters and automatically displaying appropriate diagnostic studies for review and study with the patient. By transcribing the conversation, the system automatically requests authorizations and creates orders for diagnostic studies, medications or other treatments. Providers are left then to communicate with patients, learning about them and talking about their behaviors and conditions. When the provider walks out the door all that is left to do is to sign off on the documentation and treatment orders. The priority in the exam room or screen now belongs to the patient, not the computer.

This future involves substantial changes in technology, requiring priority decisions that impact our communications, providers, processes and reimbursements. It is easier and less intimidating to make seemingly important but smaller changes than take on the larger changes. The large-scale changes, which produce improved care and value, need to be communicated in a way to create motivation and energy with a feeling of empowerment. This requires addressing human emotion, as well as individual, organizational and system accountability, just not only the technical aspect of the change.

In summary, the CIO’s active engagement with the strategy process must include prioritizing the emotional aspect of change when planning future integration. It has become extremely important to develop and understand, through the assessment processes, a way to balance the priorities and health of the individual users, along with competing burdens, resource limitations, motivations and regulations.