For centuries, the central challenge in health care was ignorance. There simply wasn’t enough information to know what was making a person sick, or what to do to cure the patient.
Now, health care is being flooded with information. Advances in computing technology mean that gathering, storing and analyzing health information is relatively cheap, and it’s getting cheaper by the day. As computers continue to fall in price, the cost of sequencing a single person’s genome is tumbling, too.
Entrepreneur Dr. Patrick Soon-Shiong is working on wearable, real-time monitors to give doctors the ability to “interrogate” a person’s individual blood cells “all the way down to the atom level” to see how a given drug works or why it fails.
Information from patients around the globe could then be compared, in theory. Computers could ultimately help doctors match specific treatments at the molecular level to the people for whom they would work best. Software might also detect patterns in data that would suggest new uses for existing drugs.
Collecting biochemical and genomic data on billions of people around the world is just the tip of the data iceberg that a few dozen health information technology experts described recently in New York at a gathering sponsored by Forbes magazine.
“You now have all of health care digitized, which is pretty cool,” said Paul Black, president of the electronic health records company Allscripts.
But it’s still unclear how to make sense of all the digital information on a big-picture scale. “There’s different approaches in the marketplace to how you would make this all be actually valuable to people,” Black said.
Some doctors are finding it valuable to “see the community information, versus just the campus information,” meaning: If they know where their patients are going for health care beyond their hospital or office, and whether they’re actually filling all the prescriptions they’ve been given, doctors make different treatment decisions nearly 70 percent of the time, Black said.
Companies like Castlight Health are betting that they can come up with ways to analyze seemingly unrelated data about how and why people use health care to improve health and save corporations money.
Castlight’s Dr. Dena Bravata said, “We can now actually marry information from [corporate human resources] systems — Are you a high performer in your company? What’s your absenteeism been? — with medical claims to really understand that, among our high performers we’re having a lot of absenteeism because their kids’ asthma is not well controlled.”
There are concerns about privacy and data security. Blackberry CEO John Chen pitched his company’s mobile devices as secure enough to meet federal medical privacy laws. But the Forbes event was more focused on the potential benefits in the new Big Data world.
There’s a lot of optimism that having a more complete picture of peoples’ health and how they use the health care system will save insurance companies money, and drive health care premiums down. Kevin Nazemi, co-CEO of Oscar Insurance, believes that a new generation of wearable wireless sensors will soon help doctors detect health problems early enough to prevent expensive treatments.
But, Nazemi said, it’s still hard for insurance companies to justify investing up front in data systems when “the value is reaped in Year 4 or 5 in a market where [people switch insurance] on average every three years. You know, dollar in, 25 cents back. How do you think of that?”
David Goldhill, who runs a cable TV network and is the author of the book Catastrophic Care, is skeptical that technological breakthroughs, even if they make people healthier, will ever tame health care spending.
“We didn’t go from 4 percent to 17 percent of GDP on health care spending because Americans got a lot less healthy,” he said. “The increase in spending in health care isn’t because, ‘Oh my God, we’re sick and if we can just cure ourselves, it’s going to go away,’ ” he said. “It’s a business model issue, it’s the way we subsidize and manage demand.”
Some see a future when wirelessly enabled skin patches are cheap, common and accumulating personal health data on a massive scale, and all that data leads to better cures and detects health problems before they blossom into expensive diagnoses. Others, an era where every minute abnormality, dangerous or not, is identified and money is spent needlessly treating it.
Yale School of Medicine cardiologist and Shots contributor Harlan Krumholz is optimistic about medicine’s ability to reel in meaningful insights in that vast sea of data. But, he says, it’s going to require a major shift in culture in clinics and hospitals. He says it’s still the norm for doctors to rely on their memories to determine whether a given drug is right for a particular patient, “as if nobody’s walking with a computer on their holster.”
Dozens of emergency medical services (EMS) personnel, including firefighters, paramedics and law enforcement officers, gathered this week to say goodbye to one of their heroes, Dan Paulsen of Pocahontas. Paulsen, who was the EMS director at Pocahontas Community Hospital (PCH), died of cancer on December 12.
Paulsen was born in Mason City and studied criminal justice at North Iowa Area Community College, where he also trained as an emergency medical technician (EMT). He served as an EMT volunteer for many years around north Iowa and worked as an EMT-Intermediate for Mary Greeley Medical Center in Ames and Story City, Dallas County Ambulance. In addition to being EMS director at PCH, Paulsen was also EMS coordinator for the Pocahontas County Emergency Response System.
Because of his amazing work ethic and boundless commitment to expanding and improving emergency medical services as both a provider and teacher, Paulsen was presented the Iowa Hospital Heroes Award in October. Here is what those who nominated him wrote:
After nearly 30 years in the health care field, Dan continues to bring commitment and enthusiasm to Pocahontas Community Hospital every day as director of emergency medical services.
In addition to coordinating emergency medical response in Pocahontas County, Dan took on a role as a class instructor to ensure everyone who goes on an ambulance call is trained at a level above and beyond what is required. This is what Dan demands, because it is what the people he serves expect. As an instructor, Dan’s supportive personality shines through. It is because of his passion and dedication to the job and the people he works with that Dan is not just a teacher or a boss – he is a mentor, role model and friend.
Even while managing his own critical personal health emergency, Dan has never wavered and has always made serving the people of Pocahontas County a priority. While battling an extremely rare form of cancer that eventually took one of his legs, Dan still brings his enthusiasm, dedication, passion and good-natured humor to all of the people he works with, whether it is fellow staff or the friends and neighbors in the community he encounters daily.
Paulsen told PCH CEO James Roetman that he was extremely proud of the PCH staff and of the care he received at the hospital. Roetman said he found Paulsen’s high expectations and commitment to excellence inspiring.
“Over the last few weeks as I had discussions with Dan, I often found myself looking in the mirror at myself and wondering how I could find coming to work or meeting my daily expectations so difficult when I had a man who cared so deeply about his profession working so hard to maintain his department while he was facing such a horrible disease,” Roetman wrote. “At that time, I recommitted myself to trying to make a difference to the people we serve even more now than ever.”
“Dan’s twinkling eyes, mischievous grin and quick wit were the first things a person would take note of,” said Laura Malone, IHA vice president of nursing and clinical services, who worked with Paulsen when she was an emergency room nurse at Mary Greeley Medical Center. “But it was his passion for his family, friends and emergency medical services that touched our hearts and made us try a little harder and love a little more.”
Paulsen, the father of three young children, was 46 years old when he died.
(From time to time, the blog features recipients of the IHA Iowa Hospital Heroes Award. These outstanding hospital employees come from across the state and work at hospitals of every size. They exemplify the courage, caring and community focus that are at the center of the hospital mission in Iowa.)
Dr. Arnold joined St. Luke’s in 2006. He has held many roles in tenure. His first position was as medical director for St. Luke’s Hospitalist Program. Under his leadership, the program was recognized twice as a leader in the nation.
In 2011 he became chief medical information officer in preparation for the hospital’s transition to Epic, an electronic health record. He gave unselfishly of his time during the planning and implementation. He was a resource to physicians as they developed their order sets. During this transition he also worked as a care provider troubleshooting problems during Epic’s implementation. His work with Epic didn’t end with St. Luke’s; Dr. Arnold also lent his expertise to nearly all of the other UnityPoint Health affiliates as they made the transition.
In 2012, he added the title director of medical affairs to his current list of duties and was ultimately named chief medical officer/chief medical information officer this year. He is also medical director of the wound healing clinic and hyperbaric chamber.
St. Luke’s mission is to provide the health care we’d like our loved ones to receive. Dr. Arnold lives the mission by focusing on exceptional care with uncompromising compassion. Most doctors in today’s society don’t make house calls; Dr. Arnold does. He goes beyond the call of duty to assist patients who struggle to get to their medical appointments. Dr. Arnold started making home visits to several St. Luke’s palliative care patients in order to make their lives easier and improve the overall quality of life.
His desire to become a doctor likely started at an early age. Both of his parents were very ill during much of his childhood and eventually passed away at St. Luke’s. Caring for his parent’s health care needs gave him a unique perspective that carries with him to this day in all of his patient and family encounters.
This time of year holds a special place in my heart. Having been raised on a century farm, I know that getting the crop out becomes the center of discussion not long after school starts in the fall. It’s talk about the moisture content, the lines at the local elevator and, of course, yields and grain prices.
In late October I had the pleasure of seeing the harvest first-hand again. On an absolutely perfect fall day, warm enough that just a light jacket sufficed, I drove my 89-year-old father in his beloved Cadillac out to a field he had farmed for decades. He told me, as he has each time we’ve driven by this field, about what a great piece of ground it was. I pulled the car onto the shoulder of the road so we’d be strategically positioned to watch the combine.
It truly was a perfect day. The sky was bright blue without a cloud providing a great contrast to the natural browns of the standing corn stalks and the grass in the ditch that was still bright green. We rolled the windows down and took it all in – the hum of the combine as it moved in a smooth cadence towards us, the cloud of chaff following it and the stream of yellow as the corn poured into the grain wagon. It was so peaceful, you couldn’t help but feel a sense of balance as well as gratitude and happiness.
Little did I know at the time, but that weekend would be my last with my dad. I’m so grateful for that day and so grateful that as his time with us was about to end, I did not have to guess as to his wishes. We had the conversations so we knew his priorities, what he valued most, and those goals were clearly understood by his doctor, nurses and caregivers.
It’s encouraging to see new efforts are underway to support these conversations. As a nation, we have hopefully moved beyond the reactionary words from previous political posturing that derailed this work five years ago. Bills have been introduced in both the U.S. Senate and House in support of advance care planning: S. 2240, the Medicare Choices Empowerment and Protection Act and HR 1173, the Personalize Your Care Act of 2013.
And Medicare may soon begin following what some private payers and two state Medicaid programs are already doing – reimbursing physicians for having end-of-life discussions with patients. The American Medical Association has created billing codes for advance care planning services and submitted them to the Centers for Medicare & Medicaid Services. If Medicare approves the codes, it will further broaden advance care planning as more private payers will likely follow suit and reimburse physicians for engaging their patients in these critical conversations.
Respected physician and talented journalist Dr. Atul Gawande is also entering this space. In his latest book, “Being Mortal: Medicine and What Matters in the End,” Dr. Gawande uses research and storytelling to demonstrate how medicine can be compatible with providing meaningful life and not just extending it. Better end-of-life care conversations between clinicians and patients can provide patients with a full and dignified life until the end.
These conversations are still not happening often enough and to that end clinicians, social workers and clergy are seeking training. “Respecting Choices” is a model used across the country and Iowa to assist patients and families in making informed end-of-life decisions. Early next year, Respecting Choices facilitator certification will be offered at IHA thru the Hospice and Palliative Care Association of Iowa, enabling a new crop of trainers to help patients and families facing a serious illness to plan the life they want, all the way to the end.
This was my dad’s final harvest and I’m thankful that it was bountiful in meaningful ways. We knew his priorities and his wishes and were able to honor what he valued.
Two years ago, Inova Health System recruited a top executive who was not a physician, had never worked in hospital administration and barely knew the difference between Medicare and Medicaid.
What Paul Westbrook specialized in was customer service. His background is in the hotel business – Marriott and The Ritz-Carlton, to be precise.
He is one of dozens of hospital executives around the country with a new charge. Called chief patient experience officers, their focus is on the service side of hospital care: improving communication with patients and making sure staff are attentive to their needs, whether that’s more face time with nurses or quieter hallways so they can sleep.
It’s a dimension of hospital care that has long been neglected, patient advocates say, and it was put high on hospitals’ agendas only when Medicare started tracking patient satisfaction and, in late 2012, shaving payments to hospitals that fell short.
“There is a new recognition that the patient is important,” said Leah Binder, president and chief executive of the Leapfrog Group, an employer-based coalition that advocates for greater health-care quality and safety.
Hospital routines have traditionally been designed to suit employees, not customers, she said. “The patient used to be maybe 10th on the list of a hospital’s priorities.”
The financial penalties introduced by the Affordable Care Act are part of a broader effort to transform health-care delivery and improve quality while reining in costs, increasing transparency and holding hospitals and providers accountable for their work.
The penalties — which for now make up only a fraction of Medicare reimbursements — are based on a hospital’s ranking relative
to other hospitals. One component is how they do on surveys of recently discharged patients. The hospitals are judged on answers to such questions as how well their doctors and nurses communicated with them, how clean and quiet the hospital was, whether they received help when they needed it and how well providers explained the drugs they were given.
Many hospitals commission additional surveys to use for their own purposes, such as marketing and branding.
Chief patient experience officers treat these survey results like sacred texts.
“The one thing I’m not trying to do is to put a mint on the pillow,” said Westbrook, who reports directly to Inova’s president and chief operating officer. “This is a different customer, with very different needs.”
But as patients’ out-of-pocket costs have risen, he said, they have become savvier, more demanding consumers.
“They are going to look on the Internet and on Medicare’s site comparing hospitals, and they are going to read comments,” he said, and increasingly, they will select hospitals based on the reviews. “It’s no different from TripAdvisor.”
Lofty Goals, Practical Implementation
Unlike Westbrook, most chief patient experience officers rise through the ranks of a health system. Like him, though, they speak in lofty terms about teamwork, leadership and developing a philosophy and culture of compassion, service and respect at their institutions.
Westbrook, for instance, talks constantly about the “Inova promise” to “meet the unique needs of each person we are privileged to serve – every time, every touch.”
That phrase had “always hung on a wall,” Westbook said. “Now, we don’t begin a meeting without an Inova promise story.”
On the ground, the focus is doggedly practical. One common innovation is hourly rounds, a system where nurses are expected to check in on each patient regularly, not wait for the person to use the call button. And the interaction is supposed to be meaningful and thorough.
“This doesn’t mean just pausing at the door, saying, ‘Are you okay? Can I get you anything?’ and off you go,” said Susan Eckert, chief nursing executive at MedStar Washington Hospital Center. “We’re telling our nursing staff that you should actually sit down, look at the patient, talk a little bit, and give them several minutes of time during which they are the only thing that exists in the world . . . It’s a very powerful experience.”
Hospitals that have put hourly rounding in place say the practice does not require extra staffing because it is more efficient to prevent problems before they occur. Taking time to reposition a patient prevents bedsores, for example, and helping patients to the bathroom prevents falls.
Another priority is having nurses call patients at home within 48 hours of their discharge, to keep their recoveries on track. (One Medicare question specifically asks patients whether they got good instructions about what to do when they get home. Hospitals can also be penalized if too many patients bounce back to them.)
Hospitals are increasingly taking their cues from patients, both by listening to the advice from new patient and family advisory councils and by using the surveys to identify weak spots.
At Yale-New Haven Hospital, where an executive director of patient relations and a medical director work together to improve the patient experience, officials have made a concerted effort to lower noise so patients can get optimal rest. Hospital staff are told to use “library voices 24/seven” and not to “vent” where patients might hear them. Overhead page calls have been eliminated, beepers are kept on vibrate, doors are closed when staff discuss cases and efforts are made to reduce alarms, pings and beeps at the bedside.
The Cleveland Clinic requires all 3,000 staff physicians to take a day-long relationship and communication class. In 2010, the hospital showed each doctor what patients had said about him or her in surveys. About half the comments were negative — and most of those had to do with how physicians talk to patients.
Doctors were stunned when they saw the results, said James Merlino, a surgeon who is Cleveland Clinic’s chief experience officer.
“Physicians were shocked, dismissive, disbelieving. They said, ‘This isn’t true, the methodology is bad, the sample size is too small,’ ” he said.
Now, he said, “we put physicians through communication training so they learn how to listen better, let the patient set the agenda and organize the encounter better.”
The result is a big increase in physician communication scores since 2008.
At UCLA Health System, parents of pediatric patients created an educational video about central-line catheters that is shown to physicians and nursing staff “to remind them how scary that catheter is for patients and their family members,” said Tony
Padilla, UCLA’s chief patient experience officer, adding that catheter-related infections can be
dangerous and even fatal.
“It drives home the message that during your very busy day as a nurse or physician, please remember: You’re accessing the child’s lifeline.”
Moving The Needle
Moving the needle on Medicare surveys can be a hard slog. Inova Mount Vernon’s composite score went up from 66.6 percent to 68.4 percent from 2010-11 to 2012-13. That means that on average, 68.4 percent of patients gave top marks to the hospital on survey questions in 2012-13. Scores at Inova Fairfax dropped and scores at Inova’s other three hospitals remained about the same.
Hospitals face a balancing act.
“We want to be attentive to a patient’s needs and wants, yet not do things just to please the patient, like overprescribing pain medication,” said Atul Grover, chief public policy officer for the Association of American Medical Colleges, which represents nearly 400 major teaching hospitals and health systems, in addition to U.S. medical schools. “You want to make sure patient satisfaction isn’t driving patient care.”
Some question whether the hospitals that score best on patient surveys are also the ones that provide the best care. Grover, for example, worries that hospitals that don’t offer amenities, such as single rooms, will be dinged in the surveys.
But some research suggests a strong correlation between patient satisfaction and outcomes, said Richard Staelin of Duke University’s Fuqua School of Business.
One of his studies, published in the journal Circulation in 2013, found that the death rate among heart attack patients was lower at hospitals where patient satisfaction scores were high, even when researchers controlled for the quality of care, meaning the care was equivalent.
Another study found higher overall patient satisfaction was associated with lower readmission rates a month after patients were discharged.
Studies have also found that hourly nurse rounds result in more-satisfied patients, with fewer falls and pressure sores.
“Patients co-produce the service,” Staelin said. “What I mean by that is that when someone is sick, the doctors can’t solve the problem without their help. … As a patient, I have to communicate with the doctor or nurse, I have to listen to the
doctor, I have to follow the instructions.”
“There are still lots of doctors who don’t believe it, but gradually the medical profession is coming around,” he added.
Indeed, several patient experience officers said some physicians at their hospitals resisted doing things differently until it was no longer an option.
The financial penalties “are brilliant,” Westbrook said. “That’s what’s driving change.”