Tip:
Highlight text to annotate it
X
There's a lot of accomplished people who are both presenting and
commenting on the papers, and you might wonder why I was asked,
and all I'll say is that I'm perhaps a FORB which means a
"Friend of Rick and Bob", so if you have any complaints
call Rick or Bob.
So talk a little bit about electronic medical records and
harnessing EHRs to better coordinate decision making for
complex patients.
And this really came out of some conversations that I've been having
with Hardeep Singh
who's one of my colleagues and he's one of the co-PIs of the
Patient Safety Informatic Center at the VA.
And what we were noticing is that there was a degree of care
coordination that was occurring implicitly,
and I'll define that explicitly in the talk,
that's occurring implicitly in the VA and maybe Kaiser and Mayo and a
few other places where you really have an integrated EHR and so that
gives you sort of the first window of how these could be powerful
tools, and some things that aren't necessarily occurring yet in these
early adopters that potentially could occur,
and that's when we start using the metaphor of Wiki.
So just to during my brief presentation here,
I'm going to describe the setting that this is most relevant is
complex multi morbid patients, and how it helps to facilitate
communication and collaboration not just among physicians,
but among all clinicians on a team;
and then to introduce some models both communication and of
collaboration, and how the EHR is then integrated within this model.
And then to talk about some of the more cutting edge elements
of it in terms of implicit communication in Wiki
communication. So, I'll start with a case presentation.
So this is Mr. Smith.
He's a 68 year-old man with type 2 diabetes,
chronic heart disease who's had a history of coronary artery stent
because of the heart disease.
And he gets a workup and then presents with a new diagnosis
of colon cancer.
So, medical decision making for him is going to be complex,
because of his comorbidities and the numerous physicians who are
involved in his care.
So, this is the traditional model of care coordination where
Mr. Smith is cared for by a primary care provider who sort of
looks at the big picture and the whole person and then coordinates
care with the specialist who might be involved.
Unfortunately this is probably in reality,
outside of maybe the VA and a few places,
this is probably the reality of what Mr. Smith's care looks like
is you see the lack of a primary care provider,
and multiple specialists who interact directly with the patient
and who may or may not communicate with each other.
So, the aims of the paper, then are really to define the terms that
occur in that communication within that model,
the role of EHR and the applications which I've cited.
So, just to move quickly now to some terms about care
coordination, and I'm borrowing the terms used by Forrest
and this was published this year in Archives of Maternal Medicine.
And he says that the traditional clinician roles where you had a
primary care provider who then coordinated the majority of care,
and you had a couple of specialists who assisted the
primary care provider.
These specialists could be procedural in that they're maybe a
surgeon who performs a procedure, or they're cognitive,
and the cognitive role of a specialist could be either through
diagnosis and or/to assist with treatment.
However we're moving more and more in both *** coordinated care and
non-*** coordinated care to co-management models.
Where you have a co-manager with principal care So, in the case of
Mr. Smith you might actually have an oncologist who becomes like a
*** in all things that are pertinent to the cancer care,
while the *** may still be involved with all the other
comorbidities that this patient has.
Or you could have roles where you have a co-manager with shared
care. So, you could imagine in this case perhaps two oncologists a
medical and a surgical oncologist are sharing the principal care of
this patient, and they differentiate roles based
on certain tasks.
So, as you can see for these models to work correctly,
communication is very important and primarily communication
provides accountability.
So, it's very clear or more clear in a primary care driven model
where the accountability is.
So, the primary care provider has the ultimate role for
accountability and typically fills in gaps when maybe a specialist
isn't doing a role that everyone else expects him or her to do,
the primary care provider might try to fill in as much as is
possible within their role.
They also serve as the communication hub that they
facilitate communication with the patient,
they facilitate communication among clinician,
and when there needs to be a face-to-face discussion between
clinicians it's often the *** who directs this or performs
this communication.
So, communication is obviously critical then to decision making
in that without adequate communication we really have
limits on the quality and the safety of care that occurs.
Costs tend to rise without communication.
And perhaps in these models where you don't have ***-driven systems
the EHR might be filling some of those roles or you can argue how
adequately it's being done.
So, let's think about improving the process and outcomes of complex
care coordination within an EHR system.
So, who makes the medical decisions when there's not a ***
coordinating care?
So, again, communication is still the key,
and So, really the most important thing is how do we communicate
accountability?
How do we define roles and responsibilities if we have just
an EHR without a *** coordinating care.
Argue right now it occurs primarily by tradition and by
social norms, so, there's traditions of what a cardiologist
does, or traditions about what an oncologist does and there might be
local social norms about how these things occur in that setting,
but you know, this is very loose and not well defined.
So, this really then presents issues of quality and safety so
you can argue we can get around some of those quality gaps by just
doing redundant or more care.
You just order more tests, so eventually a test gets done that
needed to be done.
But then this then raises safety issues,
the safety of over-utilization, safety of exposing patients to
harms, and again communication is then needed to mitigate safety
risks that come from over use.
And then of course this produces waste and higher cost.
So, perhaps communication can help to lower waste and lower cost.
So, let me move now to some specific definitions of how care
coordination might or might not be occurring within this group
of clinicians.
So, we first have synchronous communication so,
this is the most obvious thing.
This is explicit simultaneous communication between two
or more parties in real time.
So, this is a face-to-face chat in the hallway on the ward.
This is calling someone on the phone and having a direct
conversation with a specific individual or even a
teleconference or a video conference,
but it's still face-to-face, real time.
There are certain advantages to this.
It's very direct.
It's very explicit, it's real time,
and you get an immediate response.
However, it has some disadvantages and this has actually been
described by several authors that it's interruptive and it's
inefficient, and you might have someone who's performing their
daily rounds, and then they get interrupted by another clinician
who wants to have a conversation with them so it distracts them
from what they're doing on hand.
And so, that is actually a potential source of both medical
error, and then the conversation that's had.
What's recalled from that?
What's the action plan from that conversation?
It really relies on a working memory,
and so, there's all the limitations of a working memory as well
between those two clinicians.
So, in contrast there's asynchronous communication.
So, that's the process of communication that allows involved
parties to transmit and respond to communicative information at their
own time of choosing.
So, again, within a synchronous communication there is both
explicit and implicit forms.
So, an explicit form is a communication that's directed at a
specific person.
So, this is maybe the cardiologist sending in an email or a voicemail
to the oncologist.
This is definitely the tradition of writing a letter from the
specialist to the primary care provider,
or a clinical referral made by the primary care provider to a
specific clinician.
It's not necessarily real time or simultaneous,
but it's definitely communication that's directed to a specific person.
So, then with the advent of electronic health records,
you start to see the development of implicit forms of asynchronous
communication.
So, this is more open communication perhaps that's occurring through
an electronic medical record.
It happened traditionally through a written medical record where you
had a specialist's thoughts on a specific case.
Maybe what their recommendations for treatment would be,
but it wasn't necessarily directed at a specific person.
It's sort of there open for anyone to view.
So, thinking about implicit asynchronous communication;
this is an increasingly favored form of communication in
co-managed integrated health systems.
So, this is really where Hardeep and I got talking that this is
what we see is occurring in the VA more and more.
Now granted, we do have a very good form of primary care,
but often when there's conversations that are occurring
between the primary care provider and the specialist,
it's not done through explicit, synchronous communication.
It's not even often done through explicit asynchronous
communication. There wasn't an email or a telephone call from
the primary care provider to the specialist.
It was communication done through the electronic medical record.
That this is my recommendation in terms of this patient,
and the benefit of a system like the VA is that every user in the
system can see those notes, can see the linked laboratory or x-ray
results or pharmacy recommendations that were made.
So, there's clear advantages there.
It's efficient. It's uninterrupted.
It reduces the potential for cognitive load,
and it's facilitated by a great medical record like Vista or those
that are found in other places. There are certainly disadvantages.
So, now we have gaps in accountability in terms of whose
roles and responsibilities there are for each task,
and the lack of explicit rules guiding care transitions and when
is a cardiologist's role as the primary provider finished and when
it the oncologist's turn to get more involved in Mr. Smith's case.
So, more on EHRs and implicit decision making,
So, EHRs provide a window into the decision-making process.
So, if you're the oncologist wondering how much I should be
worried about the diabetes care of Mr. Smith,
I can look at the endocrinologist or the ***'s notes and see sort of
how they have been handling the diabetes care over time.
So, it does give you a window into their decision-making
and their behavior.
However that window is inconsistent to some extent.
It's inconsistent within that same patient.
They might not handle that same situation the same way every time,
and it's certainly inconsistent between patients.
So, with this patient they handle the situation in one way,
but with the next patient they might handle the situation in
another way.
So, past experience does not always predict future behavior for a
particular patient.
So, EHR implementation doesn't-- EHR implementation alone does
not clarify roles and responsibilities of patients.
You need something more than that.
And something in the paper that we define as bounded expectations.
So, you have to have a sense for each clinician within a boundary.
What is that clinician's roles and responsibilities?
What should they have the latitude to take care of?
And, what are things that are beyond the bounds of their roles
and responsibilities?
So, collaborating conditions have a confined range of expectations
regarding others' actions and behaviors.
You might argue in an integrated healthcare system,
because there's much more conversation between these
clinicians and there's much more examples of seeing how they might
have behaved in certain situations you get some-- the traditions and
the social norms are a little more locally defined and not just very
raw and very undefined.
But you still don't have explicit discussions about what is your
role, what is my role regarding some of these complicated
comanaged-care cases.
EHRs, what they could do but often don't even in systems like the VA:
So, they could coordinate activities towards explicitly
shared outcomes, they could help communicate where a patient is
along that care pathway. They could integrate iterative changes
in health status into a fixed disease management plan,
and I'll get into more of that in a minute.
Or they could integrate individual disease management plans into a
disease management registry.
They could do that in real time.
Not something that you have to go back and look at a data warehouse
and crunch numbers.
They could do that in real time but they often don't.
So, care coordination fits and starts.
So, this is sort of our non-systematic review of some of
this literature may be describing how some of these care
coordination systems might have occurred.
So, I think in the beginning there's a heavy reliance on
synchronous communication. So, this is my quote.
"One thing I learned from reading this paper-- writing this paper
was for me to question my own love and bias for interdisciplinary
team meetings."
So, as a geriatrician you're told these are the greatest things.
You get all these different specialties in a room,
sitting down and talking about a case.
So, why I've learned to unlove my love for this is and
I thought about this.
You know, we often discuss the mundane routine issues regarding
that case so, all of that is really in a way wasted effort.
We should just automatically be on a checklist and we should move on.
Those are the things that should have already happened,
and we shouldn't be discussing them.
We really should just discuss the outlier cases,
or the irregularities, or the unusual things.
A clinician's record of disease management often doesn't integrate
with a central record so what happens with these
interdisciplinary team meetings is that okay,
you made this sheet of paper that talked about where we're going,
but that then often doesn't automatically integrate with
where you are in a care plan. And it often doesn't integrate
then on each other's notes simultaneously.
You have one IDT care plan, but that doesn't then
link back to okay, what are the occupational therapists doing?
What is the cardiologist doing? What is the psychiatrist doing
etcetera, in a case.
EHRs haven't made goals concordant and implicit,
So, a lot of the discussion we've been having about coordination of
goals between clinicians and patients,
between clinicians and clinicians, EHR should allow for a single
concordant set of goals for the team regarding this patient.
But they're often not found on a EHR though in a patient's progress
notes, or in a care plan, or in a disease management plan.
And we haven't made the goals concordant across all clinicians.
So, clinicians have sort of a vague confidence about what the goals
and processes are.
Again, driven largely by tradition and by social norms,
but they don't know with specificity with certainty that
for this patient, this is where we're going.
Okay, so, this is our attempt to sort of move the idea of care
coordination forward.
And I think I talked about this element sort of the synchronous
communication to establish explicit roles and
responsibilities, and I'll move us through this- in the next couple
slides through this pathway. So, let's go back to Mr. Smith.
So, Mr. Smith's oncologist and endocrinologist realized that we
see a lot of patients with diabetes and cancer.
And there's got to be a better way to coordinate their care.
So, they sit down in a face-to-face meeting and try to establish some
bounded expectations about their roles and responsibilities as it
relates to diabetes management for this patient who's beginning to
undergo chemotherapy.
They might set clinical goals for the typical usual care patient,
who they have both seen very frequently.
They might even create a pre-established list of medical
orders for whenever a patient is going to start a chemotherapy
regimen, how should their sugar be managed,
maybe it's not that explicit for every patient,
but at least there's a set of- maybe there's a checklist for
patients on insulin.
We'll do these orders for patients on oral therapy.
We'll do these orders.
Then they create some preestablished medical orders and
treatment plans for the typical patient.
Then there is an explicit asynchronous communication by the
oncologist to the endocrinologist whenever a patient is about to
start a chemotherapy regimen.
Sends an email saying Mr. Smith is coming in for his second
round of chemotherapy.
Let's activate those sugar management orders.
So, there's both communication when a new patient enters a program,
or when the shared patient starts a new chemo regimen.
So, that's sort of where we are, the next bubble is explicit
asynchronous communication so initiation of care coordination
provide details on new consults.
So, now thinking about maybe Wiki style of communication within this
model, so, from a foundation of bounded expectations the
oncologist and endocrinologist are co-managing this patient.
So, most of the communication that would then occur would be
implicit and asynchronous.
So, they would just be describing what they were doing within the
expected- bounded expectations of their roles.
So, the endocrinologist would talk about the care orders that he or
she has done, and maybe some complications that might
have arisen.
And the oncologist would be doing the same.
Each describes usual and expected actions within the EHR.
Then there might be some explicit asynchronous communication or even
synchronous communication when an adverse reaction or something
unusual occurs.
So, you know we had an unusual case of hypoglycemia when we
did the normal treatment plan in this patient,
So, we might need to change the treatment plan for next time.
Or I made these changes because of this adverse event.
So, atypical cases that might require off-template care,
So, they directly communicated on that.
Then, thinking about that, I think these are all things that are
possible within the current EHR that's in the VA or in Kaiser,
So, all these things could happen.
Thinking forward, what are some things we could propose to do that
aren't quite there in terms of the technology?
So, going full Wiki here.
Using hyperlinks: so, we're using hyperlinks to integrate disease
management plans.
You have a separate page that has what their diabetes care is.
What is their A1C?
What were their last eye clinic visit results?
When was their last foot exam?
What were their sugars the last time they had chemotherapy?
You could even include that, or maybe that's a second page or a
sub page in this patient.
You could have process and intermediate markers of care that
go on there.
And you link to the page that's documenting prior glycemic controls.
So, you then want to link one user's edits to a shared
progress note.
So, if you then do a new foot exam and you see something change,
you make that change and it changes in your immediate progress
note, but it will also hyperlink to the disease management plan and
it would change the disease management plan
simultaneously as well.
Or you could click the link and you can go look at the disease
management plan and you say "Oh, this is what the foot exam looked
like last time. Well there's a change now this time."
Without having to thumb through a bunch of notes and read through
each note separately.
Okay, so, disease management and cost containment.
Maybe disease management plans haven't achieved the goals that
they were intended to achieve, especially their cost reduction
goals because they haven't embraced some of these ideas
about care management.
I think in many of these, and I'm over generalizing here,
and there are exceptions, obviously,
but I think there's probably an over reliance on synchronous
communication and explicit communication.
I think they all love IDTs as much as the geriatrician loves IDTs.
There's too much time focused on redundant routine,
usual expected care.
There's again, not an explicit linkage of shared goals or preset
treatment plans.
There's limited automation of laboratory and radiology results
that go directly to the patient's disease management record,
and then each patient who has diabetes and they had their own
disease management record, that should link to then a population
registry within that disease management program, so,
there's sort of a double hyperlinking there.
And then simultaneous updating of a patient's disease record
whenever a new lab, a new radiology occurs,
and then having that link to each patient's-- each clinician's
individual care plan for that patient.
So, having that more automated, automatic would then improve.
And I think the Wiki style of care coordination may address some
of those gaps.