Tom Schwieterman, MD, MBA

In a previous Physicians Practice blog post, I talked about how a majority of physicians and other healthcare providers feel the deployment of electronic health records (EHRs) has introduced new challenges to the provider-patient relationship at the point of care. I cited this belief as perhaps a reason why many physicians and health systems are hesitant to introduce additional new technology into their clinical environment.

While I understand the hesitancy to introduce new technology into the exam room, I think providers need to overcome these reservations and actively seek out high-tech solutions as a way to improve their operational workflow and enhance the quality of care they deliver. New technologies and software, along with greater connectivity and data analytics, are consistently demonstrating new capabilities for positively affecting many facets of healthcare today. While previous health information technology has introduced new challenges to the exam room experience, it is also technology that is poised to dramatically impact the point of care with enhanced provider-patient interactions and significantly improved clinical outcomes.

For instance, consider the technology advances that are helping bring greater connectivity to vital signs acquisition, such as blood pressure (BP) measurement. Caregivers can now take vital signs, review results and seamlessly import information into EHRs, eliminating manual input and reducing transcription errors. Additionally, the automation made possible by connected vital signs acquisition facilitates adherence to clinical guidelines for proper BP measurement techniques in order to achieve more accurate, consistent and reliable readings for all patients.

Now, I’m not advocating “technology for technology’s sake.” Technology needs to provide real value and must be tailored to the intricacies of your clinical environment. It must augment the way you and your patients interact and contribute to truly meaningful clinical insights for each encounter. The practice of medicine remains a deeply intimate human experience between two (or more) persons. It is this intimacy that engenders trust, and trust is an essential ingredient in any care plan. As a healthcare provider, you must ensure that digital solutions elevate that trust with patients while enhancing the clinical science.

William Osler, one of the founders of Johns Hopkins Hospital who is known as 

 famously said, “Medicine is an art based on science.” In other words, ‘how’ care is delivered is just as important as ‘what’ type of care is delivered. With EMRs now firmly entrenched as a standard practice, providers must seek out solutions that leverage the powerful informatics available to create entirely new workflows, dramatic new efficiencies and improve provider-patient intimacy. With the digital science in a relatively mature state, it’s time to invest in the ‘how’ of care delivery.

Technology integration at the point of care needs to be guided by a roadmap and guardrails that help organizations realize tangible benefits. Following are five considerations vital to help ensure a truly seamless deployment of new technology at the point of care.

 – This consideration gets to the very heart of technology integration. Challenges in the early stages of implementation often occur when the technology is not a good fit for the environment or application. In order to make an informed technology decision, you need to evaluate technologies within the context of your current clinical environment and how it performs, as well as any business objectives and growth strategies. Will existing workflows need to be changed? How does it impact the provider-patient experience? Is it flexible enough for projected growth? What value does it offer to the quality of care provided?

 – When it comes to your point of care workflows, there are two ways to look at the technology in question. The first is to determine how the technology would fit into your existing workflows. What adjustments would need to be made? Would any workflows be improved or need to be eliminated? Would the technology require the creation of a new workflow? The second is to determine if the technology would help you enhance existing workflows. For instance, real-time locating system (RTLS) technology provides insight into how a clinical environment is performing. RTLS makes capturing accurate workflow data possible, including communicating in-the-moment patient and staff locations, wait times and staff interactions, as well as providing a vast amount of retrospective detail.

 – Technology advances are bringing us closer to realizing a fully connected digital ecosystem where point of care processes, equipment and caregivers are integrated to help enhance the care delivery experience for you and your patients. As you look at new technology, it is important to determine the level of connectivity it offers and how it will connect with the digital ecosystem you are creating. Are there any additional technology or software requirements? For instance, technology that introduces a new level of connectivity to vital signs acquisition would require workflow changes but could minimize human variations and inefficiencies by normalizing and automating the process.

 – Coordinating equipment and technology deliveries to outpatient facilities is often complicated by the absence of receiving personnel, unloading and staging areas, and tools. Without proper installation or integration, promised performance levels and benefits may fall short of expectations. Facility operations or provider-patient interaction could be disrupted. You need to ask your equipment or technology vendor if they offer delivery setup and/or integration teams that can seamlessly connect the equipment or technology into your unique clinical environment. Also, without specialized product knowledge, detailed planning and careful coordination, these deliveries can become a serious headache.

 – The fact that almost no one likes change is a basic trait of human nature that must be considered during technology implementations. When managed properly, the initial reaction some staff may have to the changes introduced by new technologies can be effectively minimized and eventually eliminated as they gain an understanding of the value of the solution to your clinical environment and patients. This means letting your staff know what’s coming, answering questions, addressing concerns and explaining benefits. It also means offering structured, hands-on training with the technology and an opportunity to share feedback during the early stages of implementation.

Once healthcare providers accept that technology integration is a necessary part of the continued evolution of care delivery, these five considerations will help properly integrate the right technology that will enhance the clinical environment and the care provided to patients.

Dr. Tom Schwieterman practiced family medicine for 12 years before joining the team at Midmark. As vice president of clinical affairs and chief medical officer, he leads the company’s focus on innovative technology and new approaches that enrich experiences between caregivers and their patients at the point of care.

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Practices need to overcome reservations and actively seek out high-tech solutions.

Five Considerations for seamless exam room technology use

In a previous Physician Practice blog post, I provided a list of considerations designed to help you ensure a seamless deployment of new technology at the point of care. The end goal being that you have guardrails in place to help you properly identify and integrate technology that will more effectively enhance clinical environments and the care provided to patients.

Within ambulatory care, there is a growing need for connected technology and devices. Much of this is being driven by the consumerization of healthcare. Patients are demanding to be connected with their healthcare in the same way they are connected within other aspects of their lives. Look no further than fitness tracking devices or apps that help patients manage chronic conditions or connect directly with physicians.

This greater connectivity is paving the way for the digitization of the point of care ecosystem; which in turn promises to bring more accurate and in-depth data to the patient visit, transforming the delivery of care.

Data is the lifeblood of good medicine. Virtually all the tools physicians use in medicine (e.g., labs, imaging, physical exams, etc.) are essentially simple data-gathering tools. They help build the foundation for intervention decisions and care planning.

I vividly recall a moment when I was practicing medicine where data and paying attention to the

patient was essential to delivering good care. A mother came in with her baby, who I had delivered about 6 weeks earlier. She seemed worried and quickly started saying 'something is wrong with my baby'.. I did an exam and found nothing wrong... the baby seemed sleepy but that wasn't unusual.

But, trusting the mother, I obliged on 'getting some labs, just to be sure'. About an hour later, the lab called saying there was a critical value. The baby's sodium level was dangerously low, a level I thought would be incompatible with life. Not believing the result, I insisted on a stat repeat and it came back exactly the same. I rushed the child to the hospital and, after a few days of intensive workup, we found a genetic flaw that needed special medicine. That baby is alive and well today because of 'data' - without it, I am sure we would have lost that child.

While data sources have improved immensely since that time (e.g., higher resolution imaging, genomic labs, portable ultrasounds), most remain independently siloed data sets with limited potential. Connected technologies promise to eliminate those silos, bringing together the data to expand the physician’s ability to know and understand each patient as a unique individual and determine an appropriate clinical plan.  

For instance, advanced digital analytic tools, artificial intelligence and machine learning introduce a means for the data to take on a whole new level of capability – predicting disease progression, identifying patients who may be at risk or identifying the best choices for intervention. When the disparate data sources are combined and paired with modern smart analytics, the “data snapshot” of the patient basically goes from a blurry two dimensional picture to a high-resolution three dimensional image.

Of course, just having more data at the point of care is not enough. It must be accurate, relevant and actionable. Too often, the data available at the point of care is flawed. Medication lists are not accurate, which can lead to adverse medication selection or patient confusion. Past medical history is not complete or is poorly prioritized, causing the data to lose its informational value. A blood pressure reading may be suspect, forcing the physician to repeat the test or ignore it completely.

Combining partial data, unfamiliar data or questionable data within next-generation systems is dangerous as the inferences gained may lead a clinician down the wrong path or waste valuable time. In order to accurately and efficiently capture the value of the data, we first must shore up the individual tests to make them as accurate as possible. This includes making them as digital as possible to avoid human error. We must ensure that the data is obtained correctly and transmitted correctly...integrity of the information is essential.

As healthcare organizations look to set up their digital ecosystem, it is important they do so in a manner that helps achieve data clarity so physicians can make better care decisions at the point of care. Here are  four things to keep in mind:  

·       Care team members can (and should) do all they can to augment the provider’s precious time in the exam room to predict and populate the right data to help improve decision-making at the immediate encounter level.

·       Clinical teams need to align and create protocols for each encounter or disease type to ensure the right data is present at the point of care the first time. They need to ensure consistent evidence-based guidelines are followed for clinical decision making. Most care situations have consistent data requirements from established accepted protocols. This greatly simplifies the “what data is needed?” question and empowers care teams to design systems to achieve it.

·       Technology should be integrated wherever possible to eliminate human intervention, reduce human transcription errors and auto-populate dashboards and templates to eliminate unnecessary data handling. Every technological innovation that eliminates human touch helps improve efficiency and drive consistency.

·       Consider how you can eliminate downstream workload. Can you review a lab during the patient visit, rather than on the phone later in the week? Can you get that diagnostic study done right now to use it for advanced decision-making? Can you prepare the patient with his/her own data to allow for more self-guided next steps, such as using wearables and self-guided apps to manage chronic conditions? 

Greater connectivity at the point of care is important for realizing better care experiences and outcomes. Being able to put accurate, actionable and relevant data at the physician’s fingertips is perhaps the most important benefit to integrating new technology. Not only will it help improve outcomes, it will also allow physicians to more effectively use their valuable time with patients at the point of care.

Tom Schwieterman, MD, practiced family medicine for 12 years before joining the team at Midmark. As vice president of clinical affairs and chief medical officer, he leads the company’s focus on innovative technology and new approaches that enrich experiences between caregivers and their patients at the point of care.

Greater connectivity at the point of care is important for realizing better care experiences and outcomes

Gaining data clarity through greater connectivity at the point of care 

2018 national survey of physicians by The Doctor’s Company

, 54 percent of the more than 3,400 physician respondents felt that electronic health records (EHRs) have had a negative impact on the physician-patient relationship. Sixty-one percent also felt that EHRs have negatively impacted efficiency and workflow. The survey results offer a sobering and compelling backdrop for why physicians are experiencing frustration and burnout at record levels, with 70 percent reporting they are unwilling to recommend healthcare as a profession.

Issues created by the influx of digital record keeping intended to improve healthcare are known within the industry, but the survey results might explain why many physicians may be hesitant to introduce new technology at the point of care.

But now is not the time for physicians to be averse to technology. Now is the time for them to 

 this space and the experiences that occur in the exam room. Physicians and patients alike need to promote and design environments and workflows that leverage the power of digital records while ensuring the intimate and humanistic aspects involved in care delivery are maintained.

The bottom line is that many physicians view EHRs as intruding to the in-room experience, which is the essence of the patient-physician relationship and interaction. One reason is that the technology was not designed to benefit the physician experience at the point of care.

 that a majority of the gain from EHRs including the electronic capture of health information to enable effective billing, effective distribution of clinical information and the establishment of a single reference for comprehensive clinical data is for outside stakeholders. While physicians are responsible for the heavy lifting of populating and retrieving information from these digital platforms, most of the financial benefit is gained by those not part of the point of care experience, chiefly payers and health systems.

Not surprisingly, many patients feel that EHRs have not necessarily made the healthcare experience any better for them, either. 

 Health Network and Leigh University conducted a study over the course of its EHR implementation and found that “patients felt the disruption at the beginning and continued to feel less satisfied with their experiences after the EHR was fully implemented.”

Today’s clinical encounters still largely occur in an exam room - where physicians work with patients to conduct annual checkups, establish care plans, validate possible diagnoses and monitor chronic conditions. Arguably, the time shared between a provider and patient is the most important aspect of the healthcare journey. Yet, how that time is spent continues to be challenged.

Here are three ways physicians can help ensure a pleasant in-room experience when introducing new technology at the point of care:

Ideally, in-room digital technology should be invisible whenever possible to preserve the essence of the important interaction that happens during a patient visit. Clicks of all types need to be reduced (or eliminated), data flows from connected devices need to be automated and the user interface must be optimized for efficiency. If a computer interaction infringes on a critical patient interaction, then it needs to be reanalyzed.

Ordering tests needs to be completed with as few clicks as possible, allowing physicians to spend less time on data entry and focus more on the patient. Results from vital signs measurements should find their way automatically into the patient record. Data entry templates need to be painstakingly optimized to ensure the workflow is as efficient as possible.

These types of improvements can be synergistic with each other. When achieved in the collective, they will disproportionately increase satisfaction for providers and their patients. Often, when it comes to improving care interactions, too little attention is given to these quick wins (e.g., creating a single-order system for test acquisition or eliminating non-value add screen navigation problems).

Choose exam room equipment that is designed, or redesigned, with modern digital technologies in mind.

Because EHR technology impacts virtually every step in the care journey, the exam room layout needs to consider how EHR attributes can be optimized for workflow considerations. Computer carts or wall units should be selected to ensure that eye-to-eye contact can be maintained as much as possible during times of data entry. Major flaws, such as having the computer or keyboard positioned so that the provider faces away from the patient, need immediate correction.

Not only will these steps help physicians integrate proven technology that is currently available in the market, they will also help prepare the exam room for future technological advances. For example:

Artificial intelligence (AI) and machine learning (ML) have the potential to empower physicians with new tools to improve the in-room exam experience.

Digital analytic tools have the potential to offer new insights into a patient’s health such as identifying subtle, but significant, clinical trends that alert physicians to emerging pathology.

Other smart tools will provide augmented diagnostic capability based on social determinants of health and genomic data that personalizes therapeutic decisions with remarkable precision for each individual. An example of precision medicine would be understanding that a difficult-to-control asthmatic patient lives with a family of smokers, resides in an allergy-rich area of town and/or works in a dusty agricultural zone.

Advanced technologies such as these will continue to expand physicians’ ability to know and understand each patient as a unique individual. These tools will help physicians determine exactly what clinical plan will work for each patient while also eliminating distractions related to data entry or data transmission. Of course, this is only possible if physicians commit to integrating technology at the point of care to enhance the patient experience and the quality of care they deliver.

Tom Schwieterman, MD, practiced family medicine for 12 years before joining the team at Midmark. As vice president of clinical affairs and chief medical officer, he leads the company’s focus on innovative technology and new approaches that enrich experiences between physicians and their patients at the point of care.

Now is not the time for physicians to be averse to technology, it’s time for physicians to reclaim their space and reimage how electronic health records can improve the patient experience.

It’s time to rethink technology in your exam room 

As value-based care moves to the forefront, patient satisfaction will become a key factor in driving profitability. However, the role satisfied patients play in a successful group practice goes far beyond financial incentives. Pleasant experiences with clinicians and staff also play a meaningful role in driving positive outcomes. Simply stated, research consistently shows us that satisfied patients tend to be healthier, use fewer costly resources, and are easier to guide in disease management.

Patients are modern consumers and increasingly expect convenience, speed, and efficiency with all their transactions.  When I rent a car from Avis, I am impressed that on arrival, I simply look for my name on the board, walk directly to my car and drive off the lot in minutes. With Amazon, my orders are completed in one click - including payment and delivery information.  In their quest to improve the experience, Avis and Amazon have eliminated many of the unpleasant steps in the traditional process through use of technology.

Yet in healthcare, too many practices remain in analog mode by asking arriving patients to sign their name on a clipboard, grab a dated magazine, and sit in a crowded waiting area.  Once seated, too often they get the pleasure of sitting next to someone who is clearly ill and likely quite contagious.  Unlike Avis and Amazon, these first-touch experiences leave consumers wanting, and in some cases, worried.

Many practices unwittingly accept the waiting room experience as a non-negotiable reality and look elsewhere to improve the overall care experience.  Yet, if you ask patients, a large number will point to the waiting room as their least pleasant part of the entire visit. Why are so few organizations failing to look for ways to minimize, or even eliminate, the dreaded waiting room?

Recently at their Annual Conference, the Medical Group Management Association (MGMA) presented their 

 to one trailblazer that innovated a care path that all but eliminated patient waiting at the reception area. Cheryl Becker was honored for her innovative self-rooming initiative at Aurora Medical Group Pediatric Clinic. Becker also presented her experiences during an education session on eliminating the waiting room.

One takeaway from Becker's session is this: to succeed in this kind of endeavor, practice leaders should realize that eliminating the waiting room requires doing much more than simply converting the lounge-like space into an exam room or lab.  To truly improve the care experience by eliminating the waiting room, leaders need to take the time to fully understand their own patient flow, from scheduling through patient discharge. 

Such analysis requires practices to seek objective answers to a variety of questions such as:

•How long do patients wait in the waiting room before being escorted to an exam room?

• How long do patients wait for a medical assistant to take vitals, ask about medications, and update the EHR?

• How much longer do patients wait in an exam room before the doctor arrives?

• How much time do doctors spend face-to-face with patients?

• Do doctors have enough time to answer all patient questions?

While it is possible to answer these questions through manual observation and an old-fashioned stopwatch, the exercise is likely to be tedious and inconsistent with the actual workflow that occurs over weeks or months of encounters. 

A more efficient way to get this data is by using a real-time locating system (RTLS), the technology used by Becker's Harwick Award-winning clinic. These systems employ sensors to monitor the movement of patients, staff and equipment in real time. With this discrete technology in place, medical practices can obtain useful longitudinal data on wait times, space utilization, staff productivity, and more.  

With literally thousands of data points, the RTLS system can depict workflow reality in a manner that is hard for anyone to dispute - and that 'anyone' includes physicians. Armed with this information, practices can develop an understanding of how the patient experiences their visit from check-in to departure.  Perhaps more important, with knowledge of waits and bottlenecks, the clinic's workflow optimization teams can target opportunities for improvement with the goal of creating a seamless, value-added experience.

So next time you rent a car from Avis or order something on Amazon, remind yourself how their customer-centric technology has enabled you to have an efficient and pleasant experience.  Then consider how you can use the latest technologies in workflow optimization to improve your own clinic operations.

"Dr. Tom" Schwieterman is the Vice President of Clinical Affairs and Chief Medical Officer for Midmark Corporation, a provider of workflow technology for outpatient settings. 

Look for areas to improve patient satisfaction, such as removing or reducing the time patients spend in the waiting room.  

Author | Tom Schwieterman, MD, MBA

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