The evolution of digital technology will contribute to a more dynamic and interactive HIT infrastructure.
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AAOS Now

Published 8/1/2016
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Leslie H. Kim, MD

Using IT in Your Practice: Now and Into the Future

Information technology (IT) has disrupted numerous sectors of our economy and society. Examples abound—from Wikipedia, iTunes, and Amazon to Expedia, Uber, and Airbnb. Even personal interactions and sharing of experiences are being transformed, as exemplified by the Millennial Generation's use of social messaging apps (Snapchat, WhatsApp, Instagram). In the future, will this innovative disruption include medical practices?

The healthcare industry has largely occupied the gaps in exponentially advancing IT, but a confluence of macro trends portend change. Healthcare financing is undergoing what many view as a sea change, with fee-for-service payments ebbing and value-based reimbursements rising.

Bundling of payments for quality and performance will move organizations away from strictly volume-generated revenues toward payments for outcomes, encouraging the creative use of heretofore unreimbursed technology in the process. Widely deployed electronic health records (EHRs) incentivized by payments under the federal HITECH (Health Information Technology for Economic and Clinical Health) Act have laid the foundation for more productive future use of IT in medicine.

Envisioning a path forward
Although the health IT (HIT) infrastructure in general, and EHRs in particular, are arguably in the early—and only marginally productive—stages of development, the path forward is illuminated by the broader evolution of digital technology. Communication theorist Marshall McLuhan said that "the first version of a new medium imitates the medium that it replaces." Thus, early computers featured a "desktop" with hierarchical folders and files, just as EHRs have emulated paper charts.

However, in the next phase of web computing, searchable pages and networked links replaced folders and files. This flatter organization of data is now shifting to what some are calling "flows" and "streams." Twitter feeds, Facebook posts, Spotify music, Youtube channels, and Netflix movies are being received when and where people want them on mobile devices.

But medicine has not yet embraced these paradigm shifts and remains tethered to the metaphor of a paper chart. It has not fully capitalized on the transition from static physical medium stored in one place to widely distributed, dynamic electronic bits. Health data can and should flow in real time. Static physician-authored medical notes can and should be deconstructed. Subjective data can be entered by medical assistants or even by patients themselves. Data entry might use, for example, secure bidirectional messaging that interfaces with the EHR. Selected data elements (ie, medications and allergies) can be dynamically updated and accurately maintained by medical team members, as well as the patient, in a more open and collaborative EHR.

Objective data elements may also be imported from wearable health sensors, fitness trackers, and the Internet of things. The anticipated flood of data, however, will need appropriate filtering and analytics. All of this raw data can no longer be funneled through the doctor's note.

There is an overriding and unsolved need to improve the signal-to-noise ratio in data reporting, with IT being part of the solution rather than part of the problem. Already, hospital SOAP (subjective, objective, assessment, and plan) notes, prepopulated with reams of EHR-generated, clinically irrelevant data, bury the doctor's assessment and plan. The so-called APSO note brings the doctor's distilled assessment to the fore.

Building on the success of e-prescribing, other treatments and tests can be ordered and delivered electronically to the service provider, eliminating paper prescriptions and double data entries. Interoperability might then enable direct transmission of the results without paper or faxes—either through operational health information exchanges or through perhaps more sustainable patient-centric personal health records.

Achieving dynamic and interactive HIT involving the patient would harmonize well with other overarching healthcare goals, such as patient engagement, health coaching, shared decision making, and the collection of patient-reported outcomes for quality improvement. In a more robust HIT ecosystem, the EHR will probably devolve from a stand-alone program to network node.

Recent federal legislation (See "The Importance of the 21st Century Cures Act," July AAOS Now) would create opportunities for third-party vendors to build useful plugins and extensions. Telehealth, messaging, billing/collections, quality reporting, patient education, and remote monitoring tools, for example, could be integrated with existing office systems.

Impact on business practices
These IT-generated efficiencies synergize with business strategies such as lean manufacturing or Six Sigma that are increasingly being applied to health care. There is an emphasis on healthcare processes, which increasingly extend beyond the walls of medical facilities and fixed timing of scheduled visits.

IT software development is progressing from the database, to the user interface, to workflow layers. Data "flows," cloud accessibility, and real-time functionality enhance these processes. Linking workflow engines with business logic can empower physicians, by providing data when and where they are needed, while hopefully reducing the entry of superfluous data simply for payment justification. Checklists for care processes will be more important than checklists for billing bullet points.

Business imperatives are also placing cost controls on medical practices. Delegation of duties to staff members practicing at the top of their licensure is recommended. The fluidity of digital data can be used to transcend constraints of time (business hours in the local time zone) and space (expensive office rent).

Flatter organizational and data structures—combined with globalization and data liquidity—enable outsourcing of many front office, back office, and administrative tasks. It is quicker to move digital data to locations far outside the office than it is to move paper charts within the office, yet most medical office functions remain collocated. This is beginning to change—even for functions carried out in the physician exam room.

Current HIT usability, interoperability, security, and privacy are woefully deficient. Foremost among the complaints for many physicians, though, is the burden of data entry in the current iterations of EHRs. Physicians find themselves honing their typing skills and patients are left looking at physicians working on a computer; both are dissatisfied. Hence, the emergence of scribes who navigate through and record EHRs so that doctors can spend meaningful face-to-face time with patients. With advancing technology (ie, cloud-based software and voice-over Internet protocols), in-person scribes are now being replaced by remotely placed virtual scribes.

Human outsourcing of these office functions, however, is likely to be just a transitional step on the way to computer automation enhanced by improved voice recognition, natural language processing, and "chatbot" proficiency. The concerted development of intelligent personal assistant applications by technology companies such as Apple, Google, and Facebook suggests rapid advancement in these areas as a result of competitive market pressures.

Sweeping forces in technology, health care, economics, and society appear to be aligning to move HIT forward in positive ways. Further in the future, the prospects of ever-stronger machine learning and artificial intelligence loom: Watson-powered clinical decision support, Alexa-enabled "skills" in the medical office, virtual and augmented reality for medical education, and 3D-image capture for telemedicine. Just as computers have bested humans in various areas, it would be safe to assume that computers will improve HIT.

Leslie H. Kim, MD, is a member-at-large of the AAOS Health Care Systems Committee.