In my last two
posts, I’ve been writing about the problem of re-engaging patients in
collaborating with their providers in order to make their healthcare decisions.
Patients do not seem very motivated to use current tools (PHRs, patient portals,
private social media) to affect this collaboration, & they are already overwhelmingly
using public social media (Facebook, YouTube, Twitter, etc.) to share very intimate
details of their personal health information. I proposed that the integration
of public social information into the workflows of providers & healthcare
organizations might be an effective way of encouraging or eliciting this
collaboration. What does this mean? & is it feasible?
First several
short, but relatively interesting (I hope) digressions. What is it that we mean
by workflow? This is one of those things that everyone understands but that no
one can define, design or optimize effectively. Wikipedia defines workflow as “…a sequence of connected steps where each step
follows without delay or gap and ends just before the subsequent step may
begin.[1]”
Workflows can be abstract (models) or concrete (task or process steps). In the
case of a clinical or other medical workflow, it is the sequence of tasks that
a provider or other medical professional carries out in order to provide care
for a patient. These steps may include information gathering &/or treatment
tasks. Until recently, most clinical workflows had been developed &
modified historically by provider actions & by the efforts of medical
professional associations. More recently, workflows have been provided (at least
in part) by the use of EHR systems that have implied workflows associated with
their use. Many providers in the U.S. have gone through major changes in
clinical workflows as they have adapted to the use of EHRs in order to qualify
for meaningful use incentives offered by the Centers for Medicare &
Medicaid (CMS). This adaptation may make it harder to get providers to
accommodate to additional workflow changes.
Second, what is
collaboration? Again Wikipedia defines collaboration as: “…working with each other to do a task and to
achieve shared goals. It is a recursive process where two or more
people or organizations work together to realize shared goals.[2]” The
criteria for achieving collaboration have been deeply researched. Eisenhardt[3] has
described the criteria necessary for actual collaboration as:
- Having a shared goal structure, or explicitly agreeing to disagree on goals,
- Having a similar reward structure so that one party to the collaboration does not benefit more than the other, &
- No substantial asymmetry in knowledge or information between parties.
Given these criteria,
it is clear that the interaction, even decision making interactions, between
provider & patient &/or caregiver is not & cannot be a
collaboration. Even if they share the goal of a positive clinical outcome, they
have very different contexts for that goal; the reward structure is similarly skewed,
as is the symmetry of knowledge & information. What can happen is shared
decision making[4]
that is the patient & provider making decisions together with the resources
& understanding that they have each developed. There has been much research
on shared decision- making (SDM)[5]
that has focused on building a consensus between provider & patient on a
preferred treatment plan & its implementation. Notice that this is
different than collaboration. What is needed, then, is a workflow that
facilitates shared decision-making between providers & patients & their
caregivers.
OK – how can this
workflow be developed so that it engages both the provider & the patient.
As I have already written, the integration of public social media for
information sharing, community building & communications will be important
as will gamification of the provider/patient relationship & the use of
healthcare apps on smartphones & other devices. The easiest, & perhaps
most painless way to do this for providers is to let the EHR vendors do it.
This, of course begs several questions: what does this provide for the patient?
How can the quality & efficacy of the vendors’ efforts be ensured? Even,
how can the vendors be motivated to do this? My initial answers to these
questions are: nothing, with difficulty & with difficulty – sorry about
that. Many EHR vendors are moving in these directions, but their motivation to
provide patient functionality via their products, except for that required by
meaningful use criteria will be low. Many healthcare organizations are
providing PHRs for patients to contribute information to their personal
healthcare information, but providers have low motivation to use this “data”. There
are companies now providing private social media capabilities for healthcare
organizations, but it is just that – private. These private networks have
trouble gaining traction with patients with the possible exception of directly
messaging their provider (although many of the private networks &/or
healthcare organizations using them do not permit this).
The real solution is
to re-engineer clinical workflows so that there are (at least) alternatives
task paths that include import or evaluation of data from public social
networks, including chat & tweet streams, images, direct messages, video
etc. Such streams could be displayed as is or extracted so that data might be
available for import into other applications. Re-engineer you say… Yes, that
re-engineering. About five years ago I did a set of work on comparisons of
productivity measurements in ambulatory healthcare & two benchmark
industries: auto & information. Ambulatory healthcare had relative good
productivity based on measurements[6]
such as value added to GDP from overall revenue & value added to GDP
through Full-Timed Employee (FTE) wages. Ambulatory healthcare measurements
were generally than Auto (1998-2005) & a bit lower than Information
Industries[7].
Other productivity measurements are more focused on how organizations are
structured & managed (Total Factor Productivity, TFP) or on the effect of
multiple factors (Multi-Factor Productivity, MFP)[8]
such as research & development investment, economies of scale, managerial
effectiveness, etc. Ambulatory Healthcare had negative trends in MFP & TFP
during the 1998-2005 timeframe while both Auto & Information had highly
positive trends. It is thought that these results reflect the very large
investment made in the benchmark industries in process optimization &
workflow re-engineering. These efforts, with the exception of adaption to EHR
adoption, have yet to be made in healthcare, & it could be argued that
optimizing clinical & other healthcare workflows could result in much larger
gains in productivity subsequently resulting in positive trends in outcomes.
A provider working
through the EHR workflow could get to the history page (clinical history
including diagnosis from past encounters, clinical data for selected measures
etc.) or other relevant page & be presented with an alternative page that
incorporated data from the patient’s PHR, selected (relevant) data from tweet
& post streams, patient supplied images & video as well as potential
symptom descriptions from social media streams. This additional data could
provide valuable information not elicited by the normal EHR workflow. A good
deal of work would have to be done to determine the most effective &
productive way to provide this data as part of the workflow, so projects to
explore this should be started now.
Patient portals could
be redesigned with what we have learned about effective shared decision-
making. This would make these portals much more interesting to patients (as well
as to providers). Such portals could still provide access to patient data,
provider messaging, but could also serve as workspaces for shared decision
making with their own workflows, information sharing, game elements etc. The
combination of information from public social media available in the clinical
workflow (engaging providers with data not usually available) & a patient
portal that was a shared decision-making workspace for the patient &
provider could be a breakthrough combination.
Stay tuned for:
- a continuation with some thoughts on shared decision making workplaces, &
- I still haven’t posted the talk I had with the Future
[3] Eisenhardt, K.M. 1989.
Agency theory: An assessment and review. Academy of Management Review.
14(1):57-74. January, 1989.
[4] Shared
Decision Making (SDM) is
an approach where clinicians and patients communicate together using the best
available evidence when faced with the task of making decisions, where patients
are supported to deliberate about the possible attributes and consequences of
options, to arrive at informed preferences in making a determination about the
best action and which respects patient autonomy, where this is desired, ethical
and legal. http://en.wikipedia.org/wiki/Shared_Decision_Making
[5] c.f. Elwyn G, Tsulukidze M, Edwards A, Légaré F, Newcombe R
(2013). "Using a 'talk' model of shared
decision making to propose an observation-based measure: Observer option5
Item". Patient Educ Couns. doi:10.1016/j.pec.2013.08.005.
[6] Harper, M.J. et al. 2008. Integrated GDP-Productivity
Accounts. American Economiics Association Annual Meeting. San Francisco, CA.
1/2009
[7] Hartzband, D.J. 2008. GDP-Based
Productivity of Ambulatory Healthcare: A Comparison with Other Industry
Segments. ESD-WP-2008-11. Engineering Systems Division Working Papers Series.
Massachusetts Institute of Technology. February 2008.
[8] Bureau of Labor Statistics.
Multifactor Productivity Homepage. http://www.bls.gov/mfp/
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