One thing you are sure to find this time of year are predictions. I’ve decided to do my own not so much to join the crowd but rather because I look forward to comparing my predictions to what actually happens in a little less than a year from now. So with that, here are my predictions for the year in HIT – which ones do you think will come to pass, and which ones have I missed?
1. mHealth experiences a re-birth
mHealth is all the rage and for good reason – it holds great promise to make a significant impact for both providers and consumers alike. But while mHealth for consumers is still on the upswing of innovation and expectations, mHealth for providers is starting to pass the Peak of Inflated Expectations. Walk the floors of any HIT trade show over the last year+ and you were bound to run into iPads at every turn – not necessarily because these vendors were mobile app developers, but because they either 1) wanted you to think they were or 2) managed to make their products “accessible” via a mobile device. But accessible is not the same as usable or efficient. Perhaps the most public example of this was chronicled in a CIO magazine article that described physicians handing in their iPads after a poor experience accessing their EMR. This doesn’t signify a failure of mHealth for providers, rather it was a failure to recognize that app design is arguably more important on a mobile device than in a portal/web or desktop application. Design flaws and workflow gaps are even more exposed on a mobile device. Now that the market has begun to recognize and experience this reality, intelligently-designed mobile apps (whether native or web apps) will continue to rise to the top and carry providers through to the Slope of Enlightenment.
2. Providers begin to expect full workflow support on mobile devices
This prediction is admittedly a bit late as providers have already moved beyond mobile access to clinical results to expect full workflow support. And why not? We should not expect a physician to access lab results on his/her iPhone only to set that device down on the nursing station next to the computer terminal (that is already in use) to enter orders, document care, enter a charge, etc. Perhaps what has fueled this expectation the most is the iPad and other tablets (though not many others). Not many would expect to enter a clinical note or use order sets on a smartphone, however, the tablet form factor presents a new opportunity to do just that – support a physician’s entire workflow. Full, integrated workflow support is a (perhaps the?) critical component of sustained physician adoption of HIT. Where reasonably-sized form factors are concerned, this will also hold for mobile workflows.
3. What worked for Stage 1 will not for Stage 2
My summary of the first year of Stage 1 Meaningful Use (MU): fewer than expected (or budgeted by OMB) meaningful users in year 1, lots of confusion and less movement due to the Stage 2 delay that wasn’t a delay, and early movers characterized by the use of existing systems to meet the bare minimum Stage 1 objectives (e.g., using ED systems to achieve the 30% CPOE threshold). But many hospital IT and physician leaders have already or will soon realize that a Stage 1 strategy isn’t likely to succeed for Stage 2 and beyond. The latter stages are going to require much deeper adoption, use and exchange of health information. IT leaders will need to lay a strategic path that considers all stages of MU, ICD-10 migration, efficient revenue capture, ACO/Value-Based Purchasing and a litany of federal, state and local priorities if they are to be successful. Each of these and other priorities hinge on efficient, meaningful use (pun intended) of integrated systems that respect and protect physician efficiency (and revenue) if they are to succeed.
4. ICD-10 is not Y2K
As the fireworks exploded in Times Square last night, someone said to me “remember how freaked out everyone was at this very minute back in January 2000?” Yes, I do, and the fallout (or lack thereof) threatens to put providers and hospitals significantly behind the ICD-10 eight-ball if they consider that migration to be another non-event like Y2K. Most reports, surveys and commentary place providers and hospitals significantly behind in their preparations for migration to ICD-10. This will have to change in the coming year. But I believe the challenge and emphasis will ultimately be on documentation and not on systems simply supporting the 4-fold increase in the number and format of ICD-10 codes. IT solutions that focus on improving documentation (thoroughness and efficiency) will best prepare providers for ICD-10 and shield them from the potential loss of revenue.
5. ACOs will (continue) to get more attention than they deserve
This is not a repudiation of ACOs or what they attempt to accomplish. But ACOs have dominated much of the conversation during the latter half of 2011, and I expect that to continue. While the tenets and concepts of ACOs are likely here to stay, I still think it’s too early in that process to warrant the airtime to-date. Instead, providers will continue to focus on many of the critical building blocks required to support successful ACOs in the coming year – they just won’t necessarily be doing so in the name of a formal ACO. Do you sense a common theme? Use of integrated, efficient systems in the name of care coordination and higher-value care. While ACO will undoubtedly continue as the preferred acronym of the day, the foundational work required to support an eventual ACO model will be where the real action happens.
Happy New Year!
I wrote my very first blog post almost exactly one year ago. The topic – physicians aren’t technology-averse, they are just averse to technology that doesn’t meet their needs. An article published today by the American Medical News says “For years, many advocates of information technology viewed physicians as computer-phobic Luddites, slow to adopt and benefit from health IT. As it turned out, many doctors are enthusiastic users of technology. The key is for them to find something that serves their needs, rather than being forced to bend to the needs of the technology or the institution behind it.”
I couldn’t have said it better myself (actually, I did). The article cites physicians’ adoption of mobile technology, which vastly exceeds that of the general populace (5x greater), as a primary example of physicians adopting technology. The article continues to describe the App Challenge sponsored by the American Medical Association. Any U.S. physician, medical resident or medical student is eligible to submit an idea for a physician-focused app with winners to receive a $1,000 American Express gift card, a $1,500 Apple store gift card and a round trip for two to New Orleans for the AMA House of Delegates Interim Meeting in November. Great prizes and great idea.
mHeath has definitely greased the skids for successful physician use of IT, but the common theme is applications that support their workflow will be embraced by the physician community.
On it’s “face” (sorry, couldn’t help myself) it seems contradictory at best. How can spending more time with technology actually increase (and improve) the amount of time a physician spends with a patient?
But that’s just what a recent study found – moving certain functions online (namely, administrative functions like scheduling, bill pay and insurance verification) provides an opportunity for more efficient and productive doctor-patient visits (study results). While it only makes sense that taking care of largely administrative tasks online could improve this interaction, it goes beyond the transfer of work outside the actual visit. Providing patients with access to their health information as well as general wellness information increases personal engagement in their health, something that all providers should strive to achieve, particularly as they become more financially responsible for outcomes.
The key, according to a report by Arash Mostaghimi, MD in the Annals of Internal Medicine, is to provide “ubiquitous access to information instantly.” According to Mostaghimi, it’s not about the communication tool (e.g., email vs. social media) as much as it is about providing information by whatever methods patients prefer. This will likely take time, however, as adoption of Personal Health Records (PHRs) by providers and patients alike has been slow. And doctor-patient communication by email remained constant (and low) at 2.9% between 2003 and 2008 according to published by the Journal of Medical Internet Research. Time contrains, privacy and security, and lack of compensation are all listed as contributing to slow physician adoption.
According to Mostaghimi, waiting for the ideal or a standard technology won’t work. Physicians need to familiarize themselves with the kind of communications their patients prefer. As payment continues to move toward value- and outcome-based payment, physicians will continue to have the incentive to engage patients in their own health and improve the quality of the doctor-patient interaction.
Today, Manhattan Research announced that 75% of U.S. physicians own some form of Apple device while, unlike the general consumer market, the iPhone continues to dominate Android among physicians.
Overall, smartphone penetration among physicians has already exceeded earlier analysts’ projections of 81% by 2012. Why has Apple dominated the device market and why has smartphone adoption among physicians exceeded that of the general population?
The answer to why Apple is actually pretty simple – apple has the iPad while Android is still waiting for a real market entry to compete with Apple’s popular device. The iPad has captured physicians’ attention like no tablet (or device) before, and this trend is likely to continue as more EHR venders provide access to their systems on this device. Another potential reason for Apple’s dominance could be as simple as the availability of healthcare-related apps. Developers have shown a willingness to create apps on the iOS platform more often than on the Android OS. Of course this could be a chicken-egg scenario – more apps and more market share beget more vendors developing on the platform and the opposite. Whatever the reason, more vendors support iOS than do Android at this point. It’s also possible healthcare organizations prefer the closed app approval process required of the App Store. The open source nature of Android app development has lead to higher incidence of malware attacks, something healthcare organizations are sure to want to avoid.
As for why smartphone adoption among physicians continues to be higher than the general population – smartphones and tablets support physician workflow in many ways like no device before. Physicians are inherently mobile, whether simply rounding from floor to floor to lab in the hospital or traveling from hospital to different physician offices. Simply put, a smartphone or a tablet fit within a lab coat better than a laptop or a computer on wheels. Due to their screen size and form factor, these devices run applications that must focus on efficient user interaction and experience with near instantaneous “boot up” time.
Bottom line, where physicians’ are involved, smartphones and tablets appear to cure what ails EHR adoption.
Many in the healthcare IT industry generally believe that physicians don’t like technology. They cite years of research that shows physicians do not adopt the technology that is ostensibly purchased for them. The research, it turns out, is true – fewer than 10% of hospitals have achieved significant physician adoption of Computerized Physician Order Entry (CPOE), and fewer than 5% have achieved adoption of electronic documentation. Most of the”successful” adoption comes from Academic Medical Centers who employ physicians and residents, and therefore, can control system use to a greater extent. But 90% of US hospitals are community hospitals with largely voluntary staff comprised of independent practitioners – physicians who can and do practice elsewhere including multiple offices and even other hospitals. I would argue these community hospitals are the true test bed for physician adoption of IT.
The notion that physicians don’t use technology simply because they don’t like it is incorrect. Healthcare is replete with examples of physicians incorporating ground-breaking technologies of all kinds into their practice of medicine. From medical devices like implantable defibrillators to the most sophisticated imaging technology, physicians have shown a willingness, indeed a penchant toward adopting technology. These examples are not limited to technologies that involve direct patient care – witness their adoption of smartphones. The number of physicians using smartphones surged to 64% in 2009, and this number is projected to grow to 81% by the year 2012. This adoption rate out-paces that of consumers, among whom 65% are expected to own a smartphone by 2012.
“Usability” is often cited as the main culprit behind meager physician technology adoption statistics. Calls for improved user interfaces and screen layouts often lead to attempts at trying to weave these constructs into EHR certification criteria, for example. Indeed, the talk in the industry of late is around trying to impart usability as a requirement of Meaningful Use certification. As with prior attempts to legislate usability, however, these efforts are largely doomed to fail as the color, size and location of a button or a screen is not the primary culprit behind historically poor physician adoption.
The primary reasons for poor adoption have more to do with utility than usability. Simply put, if the technology is of no real benefit (or worse a detriment) to the physician and their practice of medicine, they will not use it. CPOE is the poster child for this challenge. Since before the Institute of Medicine’s landmark 1999 study “To Err is Human,” the industry has tapped technology, namely CPOE, as the keystone for reducing medical errors. Despite broad agreement on this as a chief benefit of CPOE, physicians have shown no real inclination to use these systems. Do physicians not believe in reducing or avoiding medical errors? Of course not. Instead, physicians struggle with systems that do not support their logical workflow and require them to provide information and respond to alerts that are better suited to other clinicians such as nurses, pharmacologists, radiologists, etc. These systems consume additional time on their busy schedules – time they cannot spare (a 10% reduction in physician productivity results in a 20% reduction in revenue).
Ask yourself, would you use something that provided no direct benefit to your daily work, or worse, provided no benefit AND took more of your time? What if that “something” wasn’t even designed for your use, would you use it then? That’s essentially what we are asking physicians to do – use technology that wasn’t designed for their benefit, but we feel is worthwhile nonetheless.
You say physicians don’t like technology? I say they don’t like technology that does not benefit their practice of medicine.