Managing the surprisingly troublesome impact of real-time healthcare on clinical decision-making

We live in an age of instant gratification. From the texts we send friends and family to the orders we place on Amazon.com, we’ve come to expect immediate results: instant responses, next-day shipping, etc.

The idea of immediacy in healthcare communications is not new. In fact, in 2015, healthcare analyst Gartner outlined a vision for what it dubbed the “real-time health system”—a landscape where healthcare professionals will be constantly aware of what’s happening within their systems and with their patients.

As a person living in the digital age, you’ve probably experienced real-time awareness in other parts of your life: the repetitive dings of received text messages, the intermittent beeps of calendar alerts, the near-constant hum as your smartphone vibrates over and over to let you know your mother, children and cousins have uploaded photos to Facebook, Instagram and Snapchat. In fact, as I’m typing this piece, I’ve heard alerts for two personal text messages that I’ve yet to look at (the temptation is maddening), four work-related emails (that I did have to stop and look at), a notification that someone commented on a thread I replied to on Facebook and more.

While there’s definitely a benefit to each of us knowing what’s happening in our expanded universe in real time—and we can easily draw a direct line to the benefits that doctors, nurses and patients would experience if they could communicate instantaneously while coordinating care—the influx of information is simply overwhelming.

And when alarm fatigue sets in, important messages get missed, the communication cycle breaks down and what was once a valuable resource becomes a liability. Overwhelmed and inundated clinicians cannot optimally use their invaluable expertise to make effective clinical decisions that deliver great health outcomes.

Aggregating, analyzing and managing the distribution of clinical information

Managing the flow of data and alert fatigue is a real challenge that clinicians and the IT teams that support them need to understand. Clinicians need “just the facts, ma’am,” so to speak, and they need to know which set of facts pertain directly to them and the patients for whom they are caring. Receiving more than enough information is not always a good thing, especially when the situation calls for fast thinking and quick decisions.

Investments made in technologies implemented over the past several years have enabled healthcare as an industry to generate very large amounts of digitized clinical information. The challenge is to aggregate this patient data in real time to generate new knowledge about a patient and distribute it in a way that does not inundate the clinician recipients with unnecessary information. Physicians and nurses should receive information they need in order to act in that moment. Everything else is noise.

Implementing communication-driven workflows

Once new knowledge is made available and deemed relevant to a given clinical situation, it’s important to enable workflows that drive this information to the right care team members, who can take action in that moment. Hospital-based communication workflows must encompass all modalities, adhere to strict security mandates and facilitate reliable exchanges among clinicians across boundaries (e.g., acute, pre-acute and post-acute care settings). This kind of clinical integration is the future of healthcare communications.

If clinicians are inundated with unnecessary information, messages and alerts, combined with a communication workflow that creates barriers to a) finding the right care team member to contact, b) finding the contact method that the clinician prefers and c) knowing whether the intended recipient received the message, the workflow is flawed and is inhibiting the decision-making that leads to higher standards of patient care.

Leveraging clinical expertise

The personal judgment of experienced healthcare professionals is irreplaceable in effective, real-time decision-making. Technological advances are no doubt improving healthcare, but human intuition can never be replaced by a new device or software. However, that intuition can be inhibited by technologies if they are not strategically implemented and managed. In this sense, real-time healthcare could, ironically, be eroding quality.

To truly leverage the hundreds of collective years of clinical expertise housed in the minds of your hospital’s medical staff—the expertise that yields great outcomes—you must remove the barriers to effective communication. Collecting patient data in real time is an important part of that. But analyzing and aggregating that data into digestible, valuable pieces of information that can be easily shared and collaborated on is the follow-through that is often overlooked.

The gravitation toward instant gratification isn’t going away. And it’s important to understand that the concept doesn’t apply simply to generating patient data as healthcare events are occurring, but also to the ability to extract the significant portions and begin collaborating with the broader care team to interpret the data and derive a plan to deliver high-value care.

The important role nurses play in care transition and reducing readmissions

In its simplest form, “care transition” is defined as a hospital discharge or movement from one care setting to another. The risk that readmissions pose to patient safety requires that transitional care processes are under constant evaluation.

Nurses are the linchpin in the coordination of patient care, and thus are best equipped to coordinate a successful transition. The bedside nurse, for example, may understand a great deal more about the patient’s needs as they travel through the care continuum than other care team members. And when those needs are communicated effectively, the nurse is given the opportunity to extend to the patient high-value care beyond organizational boundaries.

Nurses create transitional care plans by compiling all the pertinent patient information and creating instructions to be followed. Then they share the plan in detail with all members of the new care team so that the handoff is seamless for both the patient and the new unit or facility.

The most important factor in transition of care is communication during the handoff process.

What to communicate and when

The goal of the handoff is to safely transfer the patient from one care setting to another (or to discharge the patient from the hospital completely) by exchanging the necessary information with, and by effectively transferring the responsibility of care to, either a new care team or the patient’s family.

It’s a lot to put on any nurse’s plate, but by standardizing and implementing an effective and comprehensive transition communication process, nurses can elevate patient safety, avoid adverse events that lead to costly readmissions and decrease patient anxiety during the transfer process.

It’s important to remember that the transfer process doesn’t apply only to moving a patient from an acute setting to the home or a post-acute environment. There are many different handoff scenarios within the same organization, unit and floor that need your close attention.

For example, nurses should be prepared to provide handoff communication:

  • At shift change
  • During a break
  • When patients are transferred within the hospital (e.g., from the ER to ICU, from radiology to the OR, etc.)

It’s extremely important for the purposes of continuity of care that the communication between the nurse and either the new team of clinicians or the family prepares them in such a way that they’re able to anticipate the patient’s needs and make timely decisions.

At a high level, to adequately prepare the new care team, the following should be included in the handoff communication:

  • Patient care instructions
  • Treatment description
  • Medication history
  • Services received
  • Any recent or anticipated changes

More specifically, and especially in the case of transfers to a new care team or facility, an effective care transition communication plan will include:

  • Patient’s name and age
  • Reason for admission
  • Pertinent co-morbidities
  • Code status
  • Current isolation or precautions
  • Elopement risk
  • Lab results—including any pending and/or abnormal findings
  • Relevant diagnostic studies
  • Fall risk assessment
  • Any assessment findings that are appropriate to the patient’s current health

Many times, nurses on the receiving team care for patients for whom they lack pertinent health data. For example, EKG results are often left out of the transition communication between hospitals and subacute rehabilitation facilities. In this case, if a patient has an episode of chest pain, the receiving team could conduct an EKG on their own, but without prior results to compare with, they can’t successfully rule out something dangerous, such as angina. So, they may err on the side of patient safety and send the patient back to the hospital, resulting in a readmission. However, if an EKG result is included in the transition communication, the receiving team can conduct an EKG on their own, compare the results with the EKG performed at the hospital, and determine whether there is an emergent need for a readmission or the issue is something they can safely handle in their own setting.

Pay extra close attention to medication communications

While including all pertinent test results in the handoff communication is extremely important, there’s another area that needs special attention, because it causes more admissions than any other factor: medication.

It’s estimated that 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Communicating medication details is an area that poses the greatest risk for error as well as the greatest opportunity to effect a positive outcome. In fact, over 66% of emergency readmissions for patients over 65 years old are due to adverse medication events.

Breaches in handoff, such as failure to include specific details of the patient’s medication history and future dosage needs, have dire consequences.

However, defective handoffs are also known to cause problems beyond adverse events. Issues such as delays in care, inappropriate treatment, and increased length of stay arise when transition communication is not strategically planned and delivered.

There are many root causes of a defective handoff, but since nurses play the most important role in the transition communication process, you must strategically develop and communicate the transitional care plan—not only by considering what information you believe should be communicated, but by extending a dialogue to the receiving team and understanding what information they feel is necessary to provide the best follow-up care possible.

 

What to expect from MACRA: The early years

MACRA legislation passed in April 2015. When the initial version of the rule came down, the industry collectively braced for declining revenues, the avalanche of administrative paperwork and the increase in overhead costs that would be required to comply.

When the final rule was issued in October 2016, the tempered requirements seemed to point toward fewer projected negative payment adjustments in 2019, the target year for MACRA’s first Quality Payment Program distributions, and the tension subsided a little.

Even with the new allowances in reporting and threshold scores, the MACRA structure makes clear that there’s an abundance of work to be done, especially around efforts to promote care coordination and communication.

Year 1: 2017-2018

Now that we’re already into 2017, the first official reporting year, tensions are rising again because, even though most physicians acknowledge they are going to participate, the majority have not yet plotted their course or defined a compliance strategy.

And if you’re in the group that hasn’t figured it all out yet, the good news is you’re not alone.

According to a recent poll conducted by The Health Management Academy, almost half of the physician and practice leaders who participated are not moving very quickly toward adopting value-based payment models. In fact, only 4% claimed to be moving “very quickly” while almost 40% admitted to moving “very slowly” toward value-based care.

Somewhat surprisingly, the same is true even for large hospital systems. These organizations are perceived to be the driving force, the ones moving the fastest toward the end goal of value-based care, and yet, per a similar poll, few of the large systems are moving very quickly.

Only 8% of large hospital systems polled are moving swiftly toward implementing value-based payment models. – The Health Management Academy, 2017

The Quality Payment Program, however, is going to be the catalyst for healthcare organizations, both large and small, moving more aggressively toward these models in the next couple of years.

The MACRA structure and how you fit in

By now, you know that reimbursements are going to be variable based on performance, even if you’re still practicing in a fee-for-service structure and, like most, have not yet begun practicing in the more advanced tracks.

There are four participation categories, which fall underneath two broad tracks—the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) track.

The four MACRA Quality Payment Program participation categories. – The Health Management Academy, 2017

The two categories in the middle of the chart are bridge areas, and won’t apply to many providers right now, but they can be considered as stepping stones from MIPS to the Advanced APM track.

The MIPS track equates to fee‑for‑service, and most physicians will, at least initially, fall into this track. They’ll balance their steps toward embracing more downside risk by continuing to practice fee-for-service medicine, and so they must prepare to report performance metrics and have payments adjusted based on those metrics in 2019.

On the other end of the spectrum is the Advanced APM track. To reach “Advanced APM Qualifying Clinician” status, physicians must engage significantly in certain downside risk-bearing payment models. In this track, participating physicians will enjoy fewer reporting requirements and more financial incentives, while still being held accountable for delivering high-value care. The only way to sustain a profitable practice in this track is to eliminate wasteful workflows that result in inefficient and unreliable communication processes among all members of the broader care team, even if they are not directly affiliated with your practice.

Year 2: 2018-2019

In the first months of 2018, physicians practicing in the MIPS track—again, that will be most of you—will be required to report metrics in three performance categories based on at least 90 consecutive days of work. This should come as more good news, because if you haven’t started measuring yet, or you’re not impressed by your initial metrics, you still have time to pivot before the data is due in early 2018.

CMS will use that data to give each physician a composite score, which will determine the payment adjustment he or she receives in 2019.

The Quality Payment Program’s initially proposed rule was accompanied by disheartening projections in terms of payment adjustments, particularly for solo physicians and small practices. While the finalized October 2016-issued rule basically guaranteed that all physicians who submit any performance data will receive at least a neutral payment adjustment, physicians are still bracing themselves for less-than-average profit margins.

As MIPS is largely a budget-neutral program, less risk equals less reward. Since fewer physicians will be subject to negative payment adjustments in 2019 (see Image 3 below), fewer dollars will be available to distribute to those who perform well.

Only 20%—versus 87%—of physicians in smaller practices are projected to experience negative payment adjustments in 2019. – The Health Management Academy, 2017

Simply put, the best way to ensure your adjustment is as high as possible is to garner a high composite score.

Effectively coordinating care with your patients’ broader care teams as accurately and efficiently as possible to reduce waste and unnecessary overhead costs is a good first step toward achieving high scores in all four MIPS performance categories.

Back to the present

One of the goals of MACRA is to drive the costs out of treatment while still providing high-value care. Physicians will be in a much better position to deliver this dichotomy, and advance to a more rewarding reporting track, when the barriers to real-time care coordination have been broken down.

Seamless care team communication and collaboration among interdisciplinary, and often disparate, providers will be a foundation on which you can lay the groundwork for improved care coordination, which leads to less waste, improved efficiencies, and ultimately better outcomes, all of which underlie value-based care and the successful reduction of healthcare costs.

Source: “Making Sense of MACRA” webinar. The Health Management Academy and PerfectServe. March 2017. 

Watch the full webinar to learn even more about MACRA and how it applies to your practice.

The role of secure communications in your clinical integration strategy

If you could take one solution with you on your journey to clinical integration, what would it be?

Clinical integration is the unification of healthcare data, services and coordination across acute, outpatient and post-acute care. It portrays an environment where waste and inefficiency are all but eliminated from healthcare communications, costs decrease and care improves. It’s the future of medicine.

You wouldn’t be far off course if your first thought was to rely heavily on the EHR to support your clinical integration strategy. While the EHR is a valuable tool for sharing patient information within hospital systems and broader care networks, it lacks a fundamental quality that bridges the gaps between Meaningful Use and true clinical integration.

Fully realized clinical integration can only occur when the barriers of communication have been broken down, and interdisciplinary clinicians can accurately and reliably coordinate care in real time across organizational and geographical boundaries. As with most things related to healthcare communication and the sharing of information across disparate networks, securing those communications has been and will continue to be a primary focus for healthcare IT leaders. In an environment where healthcare organizations are driving toward an end-goal of clinical integration, enabling secure communications alone just isn’t enough.

To achieve clinical integration, clinicians need a solution that enables immediate, accurate, reliable and secure communications.

Immediacy in healthcare communication

Real-time communication is a crucial element of delivering high-value care. In the most critical emergencies, every second counts. The time that clinicians waste identifying the right on-call care team member to contact, and then trying to reach that person, can quite literally be the difference between life and death. Even in non-emergent situations, early detection and treatment are well-known effective preventers of worsening conditions.

Yet it’s all too common for inefficient and broken communication workflows to create time-consuming hurdles for clinicians to clear—sometimes even to just begin the conversation.

Clinically integrated settings approach clinician-to-clinician communication with a sense of real-time urgency. That’s not to say that every message should be sent with an emergency status, just that the process of identifying the provider you need to connect to and the delivery of that message should be seamless and immediate.

Reaching the right care team member on the first attempt should be an important metric for all hospital systems. To keep performance numbers high in this area, you must ensure clinicians always know exactly whom to contact for any given medical issue.

However, most clinicians today initiate time-sensitive contact to the broader care team by thumbing through a lengthy paper-based on-call schedule, making a call, and then waiting to receive a response.

Real-time clinical communication and collaboration tools immediately deliver secure communications, and even allow the clinician initiating the communication to see in real time when messages are delivered and read.

Contact accuracy

Reaching providers on the first attempt is important, but it’s just as important to reach the right provider—the one who can act on the medical issue at that moment—via his or her preferred method of contact.

It’s not uncommon for providers to have a different preferred contact medium for every variance of their schedule. And it’s not uncommon for those schedules to change at a moment’s notice. Yet many hospitals, in both small and large systems, only print the schedule and patient assignment lists once per day.

Clinicians in this setting have no way of knowing if they are accurately reaching out to the right providers via the right contact method. Manually producing a list of whom to contact and how is a process riddled with opportunity for inefficiency and inaccuracy.

Dynamic Intelligent Routing™ eliminates those opportunities for communication breakdown. A distinct capability of PerfectServe, Dynamic Intelligent Routing analyzes workflows, call schedules and contact preferences, enabling clinicians to reach the right person at the right time with just the tap of a button.

Reliable communication workflows

If your clinicians depend on inaccurate call schedules or outdated, cumbersome processes to drive clinical communications, your communication workflow isn’t reliable.

When clinicians can immediately contact the care team member they need via that provider’s preferred contact method, communication workflows become reliable and trustworthy, which leads to high adoption and improved patient care, no matter the care setting.

From improved care coordination to reduced costs

Inefficient communication workflows not only interfere with the realization of clinical integration, but also they inflate healthcare costs. For example, if a radiologist identifies a critical result in an outpatient test, the radiologist needs to contact the patient’s PCP so action can be taken right away. If the communication is not immediate, accurate or reliable, the process breaks down and the delay could result in medical complications for the patient that end up costing more to treat.

Moving a patient safely through the admissions, treatment, discharge and post-acute care processes requires a tremendous amount of coordination, good communication and a sound clinical integration strategy. The tools you use to support that communication and collaboration will play an important role in your success.

Safeguarding security: 4 tactics for secure clinical communication and collaboration

I had the honor of speaking at the 2016 Becker’s Hospital Review Annual CIO/HIT + Revenue Cycle Summit, discussing the elements needed to truly secure clinical communications with some of the best minds in the healthcare world. With a number of recent high profile news stories announcing ransomware attacks in hospitals and health systems, security and the ability to secure clinical information is top of mind for many.

Those who oversee organizational data and IT systems recognize the importance of securing communication channels containing ePHI as they build a unified communications strategy. While security and regulatory mandates are essential elements of a clinical communication strategy, to create a truly successful strategy, the needs of those who provide care: physicians, nurses, therapists and others on the care team – in any setting – at any time – must be addressed flawlessly and securely.

To do so, there a few tactics to keep in mind:

Understand what the HIPAA Security Rule actually states – There’s been a lot of confusion in the industry when it comes to HIPAA compliance and communication. I often notice that many organizations think this is all about secure text messaging, which is incomplete. The Security Rule never speaks to a particular technology or communications modality, application or device. It is technology neutral.

HIPAA compliance is about the system of physical, administrative and technical safeguards that your organization puts in place to to ensure the confidentiality, integrity and availability of all ePHI it creates, receives, maintains or transmits. Because of this, there is no such thing as a HIPAA-compliant app.

Understand care team dynamics – Care team members are mobile and they employ workflows to receive communication based upon situational variables such as origin, purpose, urgency, day, time, call schedules, patient and more. The variables determine who should be contacted and how to do so for every communications event.

For this reason, third parties (hospital switchboards and answering services) and disparate technologies are used in organizations’ clinical communication processes. Understanding this variety of technologies and actors is key to accurately assessing your organization’s compliance risk. And, coming up with strategies to effectively address that risk is key.

Secure text messaging is essential, but it’s not sufficient – While secure messaging is an essential component of your overall strategy, it’s not sufficient because:

  1. it requires the sender to always know who it is they need to reach—by name.
  2. it requires the recipient to always be available to other care team members 24/7.

These requirements are inconsistent with the complexity inherent in communication workflows that enable time-sensitive care delivery processes, because they don’t address the situational variables I described above.

Secure messaging is only one piece of what should be a much larger communications strategy—one that should address clinician workflows and multi-modal communications channels for all care team members.

Your goal should be to enable more effective care team collaboration – Organizations often focus on achieving HIPAA-compliance. This is a flawed objective. The focus should be on achieving more effective care team collaboration. If this is done effectively, achieving HIPAA-compliance will come along for the ride.

Six essential capabilities – An effective secure clinical communications and collaboration strategy will include the following six elements.

  1. It will facilitate communication-driven workflows that enable time-sensitive care delivery processes. An example of a communications-driven workflow is stroke diagnosis and treatment. When a patient with stroke symptoms presents in the ED, one of the first things the ED physician does is initiate a communications workflow to contact the neurologist covering that ED at that moment in time, while simultaneously notifying and mobilizing a stroke team to complete a CT scan to determine if it is safe to administer tPA, the drug that arrests the stroke. Time is critical. Healthcare is chock full of these kinds of workflows, executed every day in every hospital by the hundreds and thousands.
  1. It will provide technology that automatically identifies and provides an immediate connection to the right care team member for any given clinical situation—this is nursing’s greatest need! Your strategy should be to bypass third parties and eliminate all the manual tools and processes used to figure out who’s in what role right now given the situation at hand. Ignoring this need means you won’t achieve adoption, which means your organization will still be at risk.
  1. It should extend beyond any department and the four walls of the hospital. It should enable cross-organizational communication workflows. This is increasingly important under value-based care where care team members must collaborate across interdependent organizations to deliver better care.
  1. It should secure the creation, transmission and access of ePHI across all communication modalities—not just text messaging. Enough said!
  1. It should integrate with your other clinical systems to leverage the data within those systems to facilitate new communication workflows. This is key to enabling “real-time healthcare.”
  1. It should provide analytics to monitor your communication processes and continuously improve those processes over time.

With these capabilities in place, secure clinical communication simply becomes another positive result of implementing a broader care team collaboration strategy, designed to address clinical efficiency and improve patient care delivery.

Mobile charge capture: A simple change to your business practices with significant outcomes

While there are conflicting perspectives on the physician shortage, there is resolute agreement that the demand for primary and specialty care is growing due to the expanding older population. Concurrently, the challenges for physician practices, which are needed to provide that care, are also increasing. Older patients require 2–3 times the amount of specialty and primary care to treat and manage chronic conditions and age-related illnesses. Unfortunately, in today’s ever-changing healthcare environment, many practices are struggling to survive.

As has never been experienced previously, practices are facing daunting obstacles to care delivery due to rising operating costs, regulatory burdens and barriers to receiving pay/reimbursement. The cost to operate a practice has increased at twice the rate as the consumer index due to increasing rent, malpractice insurance, liability coverage, health insurance and personnel expenses. Mounting regulatory requirements have not only served to increase overhead, but have also consumed valuable patient care time with oppressive documentation and administrative requirements for HIPAA, Meaningful Use, prior authorization and quality mandates.

Now in the wake of the time-consuming and costly protracted transition to ICD-10 and EHR implementation, physicians are struggling to get paid. In part, this is due to the ACA which has introduced reimbursement cuts and increased penalties. Last year, the Centers for Medicare & Medicaid Services (CMS) began to apply the value-based payment modifier to adjust reimbursement amounts to reflect the quality and cost of care provided. Those practices not meeting performance standards will receive less reimbursement. In addition, this year, the penalty for non-participation in the Physician Quality Reporting System (PQRS) increased to a 2% reduction in the CMS market basket update. Further, the increased number of patients with insurance provided through state exchanges or the Federal marketplace has exacerbated the payment problem. These patients typically have very high deductibles, along with a 90-day window to pay premiums, posing more obstacles to the collection of co-pays and out-of-pocket expenses. Notoriously, it should be noted that the CMS also takes longer to reimburse physicians as compared to private payers. Moreover, the ICD-10 transition has resulted in increased claims denials, resulting in labor-intensive, time-consuming efforts to overturn the same.

Confronted with these challenges, paradoxically, many physicians have had to reduce the number of patients they see, further eroding financial return. However, for those struggling practices, indiscriminate cost slashing is not the answer as physicians must finely balance improved operational efficiency with the achievement of the aims of quality patient care. This is where innovative technology can play a key role. Smart investment needs to target technology that is able to:

  • Reduce operational expenses
  • Ease regulatory compliance and the documentation demand
  • Facilitate physician workflow
  • Increase patient care time
  • Generate more revenue

One such technology that meets the above criteria is mobile charge capture functionality within a secure messaging application. This would enable physicians to quickly and easily capture charges at the point of care and automatically and securely communicate this information to billing staff or a billing application.

To ensure there is no increased burden to physicians, this process must only take a couple “clicks” or a matter of seconds. For example, the application must have immediate accessible “favorite” codes composed of those services and diagnoses used most frequently and denoted by the terms most familiar to that particular practice, rather than formal codes and code definitions. Additionally, when needing to find a rarely used code not contained within favorites, the application should provide decision-support enabling the easy selection of the right ICD-10 code to be associated with the CPT code. Also, there should be code bundles available so multiple code combinations can be assigned to a patient in a single click.

This prompt and speedy process replaces the manual paper-and-pencil method in which physicians retrospectively attempt to make a note of the procedures performed —sometimes days or even weeks after the encounter. Consequently, quite often, not all services that were provided are recalled. These “notes” were then provided to the practice billing team who then must interpret the right procedure and identify the correct codes for billing purposes. Often because of the lack of detail within the notes, the specific details of the procedure are lost, reducing the amount of reimbursement received on top of the lost charges due to poor memory.

These issues could be virtually eliminated with smart mobile charge capture functionality. Additionally, this functionality enables the ability to easily add and document PQRS codes while facilitating patient rounding, with a customized patient list and direct access to previous charges, and with the ability to rapidly “clone” them for the day’s visit. This information would also be visible across the entire group of physicians, if desired.

By automating and expediting the charge capture process, there is a direct impact on the practice’s financial homeostasis:

  • The elimination of lost charges and improved coding specificity directly translates into higher revenue.
  • The coding decision support and the inability to mismatch CPT and ICD-10 codes mean reduced potential for costly and time-consuming audits and claims denials.
  • The easy documentation of PQRS avoids the 2% CMS penalty and facilitates compliance.
  • The immediate transmission of charges to billing staff speeds the time to billing, reducing the amount of time to payment received.
  • The number of FTEs required to support the coding and billing process can be dramatically reduced markedly decreasing operational expenses.

Most importantly, such technology can allow physicians to spend more time doing what they want to do and what we need them to do—caring for and treating patients.

3 “must-haves” for simplifying complex clinical communications

Part 3 of a 3-part series in conjunction with our nurse leadership webinar series.

Imagine a world where you launch the EMR, review a patient’s chart, and want to discuss it with the covering cardiologist that day. You click a link for the cardiologist within the EMR and it references that provider’s group workflow processes, reviews their schedules and monitors their momentary status to direct you to the correct provider. Then you type your message. The patient’s information is pulled from the EMR and is securely routed to the recipient based on their contact preference in that moment. It can happen – but this is not the norm in most healthcare facilities today.

Practicing medicine today is complex – clinicians need to consider an ever-changing landscape, federal and state regulations, not to mention the many different innovations designed to help streamline everything from care delivery to reimbursement. Adding to the complexity are the many different providers treating patients, working across various care settings with large care teams.

Given the vastness of these care networks, it can be daunting – albeit necessary – to coordinate care. One way to help connect clinicians in all care settings and improve care team collaboration is through a comprehensive communication solution.

It’s important to first understand why clinical communication is complex and why many of the technologies implemented today aren’t solving the issues clinicians are facing. Factors such as the patient’s reason for contact, the physician’s location, team coverage, degree of urgency and unassigned ER calls all impact the communication process.

Looking across varied care settings, people, processes and preferences also differ. Between inpatient and outpatient facilities, medical group practices and post-acute care, there are many variations in care team communication strategies and approaches that make it prone to gaps and breakdowns. In fact, one of the most frustrating parts of a nurse’s job is the daily battle to determine the correct covering provider.

In this complex environment with so many participants, the continuum of patient care demands that communication solutions span much further than the four walls of a hospital or practice. And as healthcare delivery models change, it’s imperative that care coordination, and the communication that drives it, be streamlined and efficient across all of these settings. When looking for a platform to simplify clinical communication, healthcare organizations should keep the following three “must have” capabilities in mind:

  • Span the entire care continuum: A comprehensive solution must address the needs of all care team members across all types of settings – from a single hospital to a multi-site system, as well as outpatient practices and care settings. They all have different demands and communication requirements. For example, larger practices and hospitals need advanced directory capabilities to bring the opportunity to coordinate care based on facility, group or ACOs, with the appropriate workflow processes built in. In addition, the solution should have the ability to generate real-time patient updates – such as when the patient presents to the emergency department, is discharged home, or when important results are available. This is essential to timely coordination of care. Finally, it’s imperative that the communication solution connect to the organization’s other HIT systems to maintain integration for alarms and alerts, such as if stroke team is activated. It’s critical that covering providers respond quickly and that a back-up process is in place.
  • Provide a standardized, yet flexible way to communicate: Clinicians should have flexible, yet standardized communication options that allow their messages to be routed appropriately and securely, and account for today’s technology. Gone are the days of referencing binders, faxed schedules or notes taped to the wall or desk. Once the communication process is initiated, the process should seamlessly connect you with the correct covering provider for the clinical situation at hand – whether through call, text or via a mobile app.
  • Address process complexities with intelligent routing: Schedules, workgroup rules, team mobilization requirements and escalation paths should all be configured so that you are connected to the right care team member with real-time accuracy. A solution with dynamic intelligent routing is able to deliver messages at the right time, to the right person in any given clinical situation. Clinicians should be able to customize based on their device and delivery preferences, and make changes based on their activity (e.g., what to do with a call while in the OR).

The goal is simple: Remove the variability, the hand offs and the touch points that introduce risk and opportunities for communication breakdowns. Initiate the communication in the manner you wish, and let the process connect you to the correct covering provider for your clinical situation at any moment in time.

While efficient clinical communication is a challenge, the right solution can lead to tremendous benefits for every care team member, as well as the organization. The solution must be comprehensive, providing standardization and the ability to streamline the communications process. By implementing technology that addresses these three areas, healthcare organizations will not only be able to improve clinical communication, but will ultimately improve the experience for patients, and the extended care team.


Interested in learning more? Read part 1 and part 2 of this series on nurse leadership in care team collaboration.

Nurses need innovative care team collaboration technology

Part 1 of a 3-part series in conjunction with our nurse leadership webinar series.

Six years ago, the National Academy of Medicine (NAM), formerly the Institute of Medicine (IOM), recommended that nurses lead inter-professional collaboration and healthcare delivery improvement and redesign. They noted that nurses are uniquely positioned to do this since, given the care setting, they are quite often the primary patient caregiver. As such, they serve as the virtual linchpin of care—connecting the various care providing professions while coordinating patient care across the entire care team. Toward that end, nurses are responsible for over 90% of physician communications while directing over 80% of their own communications to the broader care team.

While some inroads have been made in regard to this IOM recommendation, there are formidable challenges impeding significant progress. As the industry transitions to value-based-care, nurses are being held increasingly more accountable for patient outcomes and experience. Paradoxically, they are concurrently being asked to perform more indirect and non-patient-care tasks which reduce the amount of time at the patient bedside—one of the strongest predictors of positive patient outcomes and experience.

One such activity is care team communication.

Specifically, nurses have reported that difficulty communicating with the care team has decreased direct patient care time. One survey study found that 75% of nurse respondents reported wasting valuable care time just attempting to communicate with physicians and other care team members. In part, as 50% of the respondents acknowledged, this is because they are unaware of the right care team member to contact for the clinical situation at hand. The latter explains why the majority of physicians reported being frequently erroneously contacted when not the right physician for the situation.

These recalcitrant obstacles to care team communication and collaboration have served to delay patient care and prolong patient wait times. No one is more acutely aware of this than the nurse.

Nurses quite often find themselves waiting for physicians to return phone calls/pages while their patient needlessly suffers. As the nurse struggles to coordinate care, no one is more cognizant of the impact of missed care or delayed transitions on the patient and the patient’s family. Moreover, no one is more handicapped by the limits of fragmented communication technologies that have not successfully overcome these challenges because they only address a small component of the overall problem. And no one is in more need, than the nurse, for innovative technology that is able to immediately connect the right care team members to facilitate timely collaboration.

The good news is that this technology is now available. However, when evaluating the various care team collaboration platforms, it is important to avoid common pitfalls. Here are a few guiding principles to keep in mind:

  • While secure messaging is a salient feature of the platform, it is not wholly sufficient to address these communication obstacles since it is dependent upon two flawed assumptions.
    1. The recipient, such as the physician, must desire to be contacted at all times for all situations every day of the week.
    2. The sender, for example, the nurse, knows who to contact in every single situation.
  • All of the care team must be on the same platform. As the IOM noted, “True inter-professional collaboration can be accomplished only in concert with other health professionals, not within the nursing profession alone.” This holds true for any other profession.
  • Most importantly, the technology must be purposefully designed to overcome the known referenced obstacles. To do this, it must be able to automatically identify and provide immediate connection to the right care team member for that particular clinical situation. This type of complex logic requires that for every single communication by every care team member, the contextual variables of the particular message must be analyzed in real time to ensure the communication is routed to the correct individual.
  • The care team collaboration platform capabilities must transcend the walls of any one facility. Nurses, as well as physicians and other care team members, quite frequently need to contact team members who work in and across other facilities and locations. The platform must be able to support this communication and the intelligent routing capabilities must extend to provide immediate identification and connection to these care team members when needed.
  • Ultimately, the care team collaboration platform must have proven functionality to reduce communication cycle times. Reducing the time to connect and close the communication loop translates into care team efficiency and increased patient care time. As every nurse knows, this means speed to treatment, improved patient experience and improved patient outcomes.

Nurses are indeed perfectly positioned to lead inter-professional collaboration and healthcare delivery improvement. However, it is critical that they are provided with the technology that will allow them to overcome all the challenges this entails.

Let us not repeat the mistakes of the past—providing nurses with inadequate technology in response to which, they must find a work around—increasing their effort and workload in the endeavor. Quite sincerely, healthcare improvement and reform depends on it.


Interested in learning more? Read part 2 and part 3 of this series on nurse leadership in care team collaboration.

The impact of a unified communications initiative on a health system

Listen to the podcast here, or read the transcript below. 

Introduction: You are listening to Health IT voices. Broadcasting live from Chicago, Illinois, and direct from the HIMSS15 exhibition. HIMSS – transforming health through IT. Today’s show is brought to you by Health IT Outcomes, bringing you the latest on the technology and people driving health IT. And now here are your hosts, Todd Schnick and Kelly Riggs.

Todd: All right, good afternoon and welcome back to the show. I’m your host Todd Schick, joined by my friend and colleague, Kelly Riggs. Good afternoon to you sir. They have saved the best for last.

Kelly: Oh yeah, we’ve put a little pressure on him as well, but I’m looking forward to a great interview.

Todd: It’s going to be a great conversation. Before we go there, Kelly, a quick shout out to Health IT Outcomes for making this great day possible.

Kelly: You bet. Really appreciate them having us as a part of the show, and you want to make sure you check them out. HealthITOutcomes.com.

Todd: All right. Let’s get to this great conversation. We’re now joined by Terry Edwards, the CEO of PerfectServe. Terry, welcome to the show.

Terry: Thank you. Glad to be here.

Todd: Glad to have you. Thanks for carving out some very valuable time at the end of a long day. I’m sure it’s been a good day for all of us. Before we get into our conversation, take a quick second. Inform the audience a bit about you and your background, and then give us the 10,000 foot view of PerfectServe. What do you do? How do you serve your market?

Terry: Sure, sure. Well, I’ll maybe start with a little bit of a story here. I got involved in interactive voice response technology back in the 1990’s and when I got involved in that industry, my wife is a registered nurse, and she went to work for a solo practice pediatrician, and I used to observe how she would manage the call process. She would take calls for this doctor on the weekends occasionally, and I would observe how the process worked with patients needing to connect with her around an urgent situation, and how convoluted it was. And so, that led to an identification of this problem around communications in healthcare and me then founding PerfectServe. So today, PerfectServe is a pretty meaningful company in the space. We essentially are a communication and collaboration platform that’s focused on uniting the care team members – the physicians, nurses, and other providers.

Todd: We talked a little bit before the interview and you were explaining to me it is an enterprise resource type of application. Clearly, it has to be very extensive to begin to mold so many different disparate pieces into one arena. How do you implement?

Terry: Yeah. The heart of the platform is its ability to enable what we refer to as a communications-driven workflow. And so, let me explain what I mean by that. Let’s say that you were to show up in an emergency department, and the doctor thinks that you might be having stroke symptoms. So, they’re going to then kick off a workflow that’s based on stroke diagnosis and treatment. And that involves reaching out to the neurologist who’s covering that emergency room at that time. There might be a whole stroke team who has to get in to perform a CT scan for you. And this is important, because there’s a drug that arrest stroke called TPA, and there’s a certain time window when that drug has to be administered. And if it’s not administered in that time window, bad things happen. So, an example of the communications part of that is contacting the on-call neurologist and mobilizing that team and getting them to come together to provide the care that’s necessary. So, PerfectServe would automate that kind of a communications process, for example. So that’s what we do.

Todd: You said earlier that your role is to unite the care team members. Now I think the average consumer out there would say, ‘Well, wait. That’s not happening already?’ I mean, how big of a problem is that?

Terry: It’s a big problem. In fact, we conducted a Harris poll survey that we released this week, and we surveyed nearly 1,000 providers. I believe about 750 were actual clinicians. The others were administers of large practices or hospitals. But of the clinicians, 54% of them, or 53% of them, often times don’t know who the right care team member is in a given clinical situation, and that’s because the workflows are complex. So much of healthcare is role-based communication, and who is in this role. Like, I talked about the neurologist. Who is in the role of the neurologist providing care at this hospital right now? Because that changes.

Todd: Well it’s interesting that you use the phrase communication and collaboration, because basically what we’re talking about is a variety of silos that, if they don’t hand off and transition well, you can lose a lot of valuable information along the way.

Terry: That’s right. That’s exactly right. So, communication to me and to us is a part of collaboration and this notion of collaboration is really more important as the industry shifts to value-based care models, and it’s not about the doctor or just the patient anymore. It’s about the whole care team. And so we’re really focused on trying to bring the care team tools that will allow them to be effective at collaborating with each other.

Todd: Well, you were reading my mind – the value-based delivery. That becomes a significant aspect of this. It’s really difficult to even drive that without the collaboration.

Terry: Yes, yes. Under a fee-for-service model, there’s not an incentive for providers to communicate with each other in many cases. But, if you have multiple providers who are all under, say, a risk-based sharing contract for a population of patients, then that’s going to drive new communication work flows and youth cases that aren’t occurring today. And there, you know, like contacting the neurologist. Some of them are very difficult to implement in an efficient way.

Todd: Absolutely. Well, lest you think I missed it, I did pick up on your secret weapon that Mrs. Edwards is a registered nurse. How critical has that been? Because they’re a critical link between the patient and the doctor. How valuable has her insights been to help you understand what really needs to happen here?

Terry: Well, she’s not practicing anymore, but she was integral to allowing me to, you know, to see the problem. But even as she describes it, within healthcare, I remember somebody asked her the question, ‘How bad was it?’ It’s kind of like, well, you don’t really know how bad it is until you have a solution, and then it’s like, how did we live without this before?

Todd: Hey, I want to get a little bit specific with you Terry. Let’s talk a little bit about PerfectServe. Talk about some of the features that you offer healthcare providers in a unified communication platform that other vendors may not.

Terry: Sure. Well, I’ll start maybe just talking about texting, because it’s been a segment that’s been emerging and it’s being driven by the rise in smartphones and, you know, we’ve all adopted it from a consumer perspective, and we incorporate those capabilities, but a true platform to really be comprehensive has got to bring in voice, it needs to bring in voice messaging, it needs to be multi-mobile. You’ve got to be able to initiate a communication via the phone, via a mobile app, via the web. It’s got to connect up to the primary clinical systems, so we receive data out of different systems, for example, and we’ll route that data accordingly. Say, a lab result, for example, or a new admission notification. So the other thing is, as you think about all these different modes, and then you have to do the various routing, you have to make sure that they’re all secure. So the issues around security aren’t just secure text messaging. It’s secure communications. And that, you know, in addition to the workflow capabilities that I talked about earlier, the ability to secure all the communications at an enterprise level is, we think, distinctive to the PerfectServe organization.

Todd: IT departments hyperventilate when you change their worlds, the finances of provider are very sticky and tricky and they’re limited with resources. How do you overcome some of those challenges?

Terry: Well, you know, within the hospital enterprise or large integrated delivery networks, you know, IT organizations, you know, they have their own way of buying and things like that and the buying processes and evaluation processes can be very, very challenging, but we have been able to work with some of the largest and most prestigious systems in the country, like Advocate, for example, here in Chicago. One of the leading health systems in the country – a leader in value-based care and we’re deployed across that entire system, and we’re employed across the entire system because we’ve been able to meet their needs, both from an IT security standpoint, and as well as a workflow standpoint.

Todd: So here’s an interesting question for you. We talk about outcomes. What physicians care about, ultimately, is outcomes. Is that the perfect metric to validate the efficacy of a system like yours or is there something else that we can measure and understand?

Terry: Well, what we’re doing is we’re enabling clinicians to speed the time to treatment, ok? So if you speed time to treatment, that will have an impact both on quality, as well as on operational efficiency. Now, there are a lot of other things that can contribute to both of those factors, but we’ve been able to do studies, for example, from an operational efficiency standpoint, where we’ve been able to improve throughput for example, in emergency room. We’ve been able to see hospitals see a reduction in code blue events. That stroke example that I gave, St. John Hospital and Medical Center, part of the Ascension health system in Detroit, when they implemented the process that I described, they were able to administer TPA to three times more patients who presented with stroke than they did the previous year even though the patient population was the same. So, by improving that communication-drive workflow, more patients walked out of that system alive who presented with stroke.

Todd: Sure. Speed becomes a very interesting metric. I agree.

Terry: Yes, yes. And we’ve been able to prove, we’ve done studies where we’ve definitely proven a reduction in cycle time. I had the opportunity to give a presentation earlier today here at the event with Memorial Care, and we did a before/after time motion study of nurse to physician communication cycle time, and they experienced a reduction in average cycle time by about two thirds. From 45 minutes on average down to just under 15.

Todd: Wow. Wow.

Terry: And the thing that’s interesting is these kinds of communications are occurring hundreds or thousands of time every day in a given hospital. So in Memorial Care’s case, I believe they’re probably about five to six hundred times a day.

Todd: Wow. Unbelievable.

Terry: And this is all about the care delivery process, and it’s the interaction that occurs in those communications that determines the, you know, the action that needs to be taken to provide treatment.

Todd: Well we’re here at HIMSS15. Is PerfectServe making any key announcements we should be aware of?

Terry: Yes, yes, yes. So we just announced our broader product development strategy and we’ve introduced that under the PerfectServe Synchrony brand identity. And that effort is about expanding from the communication-driven workflow for doctors to the entire care team, like we’ve described. So, we’re going to be rolling new capabilities out next quarter, and then those capabilities will be available by the end of the year or early the first of next year. And Memorial Care, who I talked about earlier, will be one of the first systems in the country to deploy this comprehensive solution. There’s not another one like it. Fantastic market. So, we’re excited.

Todd: Yeah, congratulations. We look forward to talking about that next year.

Terry: Great, great.

Todd: Terry, we’re out of time. Before we let you go, how can people get in touch with you should they have questions and where can they learn more about PerfectServe?

Terry: Sure. Well they can learn more about PerfectServe at www.perfectserve.com. I can be reached directly at 865-212-5700 or terry.edwards@perfectserve.com.

Todd: Terry Edwards, the CEO of PerfectServe. Terry, real pleasure to have you. Thanks for stopping by and joining us.

Terry: Thank you.

Todd: All right. Well that wraps our day one coverage here from HIMSS15. This has been Health IT Voices broadcasting from HIMSS live from Chicago. On behalf of myself, my cohost, Kelly Riggs, and all of us at Health IT Outcomes, this is Todd and Kelly signing off. Healthcare IT Voices will return tomorrow. We’ll see you then.