I have previously
written about the integration of public social media into clinical workflows in
order to improve the engagement of patients in collaborating with their
providers to make healthcare decisions. In that post (http://posttechnical.blogspot.com/2013/12/clinical-workflow-other-arcane-rituals.html),
I said that the inclusion of information from public social media such as
Facebook, YouTube, G+, Twitter etc. into clinical workflows might provide
important information not otherwise available to the clinician & also might
serve to more deeply engage the patient in clinical decision making as
information that they independently provided would be part of the decision
process. I wrote in general about how this might work – here’s a more detailed
(& nuanced) view.
Providers are very
protective of their workflows, especially workflows that involve patient
interaction. In the past several years, these workflows have had to change substantially
if a provider is going to qualify for meaningful use, that is specific use of
electronic health records in order to qualify for higher reimbursements from
CMS (the Centers for Medicare & Medicaid Services, HHS). Most providers I
have talked to recently are not interested in more workflow changes, especially
if they are not going to be paid for them. There is, however, one motivating
factor that can change this - improving patient outcomes. If providers could be
convinced that including information from external sources, such as public
social media, in their patient interaction & diagnosis workflows, then it
might be possible make this integration work productively, but several
principles would have to be followed:
- Change the current EHR-based workflow as little as possible
- Maintain the information from the external source separately from the EHR so that the EHR workflow can still be executed as currently
- Provide information that is either unique & relevant to the diagnosis & treatment, or enhances information already available through the EHR.
I’ll describe a
possible workflow scenario that follows these principles in a little, but
first…
I also described
the criteria for collaboration in that previous post. If the patient is going
to be re-engaged in making medical decisions with their provider, there has to
be a model for how to do this. As I stated previously, that model is not
collaboration-based because the criteria for collaboration: shared goal
structure, similar reward structure & symmetry in knowledge or resources,
are not met by the patient-provider interaction. The model for this interaction
is shared decision making, so an additional principle for this workflow change
is to provide the context for shared decision making by the patient &
provider.
- relationship building between patient & provider,
- introducing choice with respect to treatment
- offering options
- deferring decision
- discussing & deciding on a treatment plan.
- Risk-reward trade-offs
- Use of decision aids (paper-based, electronic etc.) for education
- Elicit preferences
- Discuss preferences
- Reach consensus
Shared decision
making is most appropriate in situations where there are several possible
treatments with somewhat similar side effects, costs & outcomes (if there
is one most effective treatment, the need for shared decision making, but not
for transparency, is moot). This process only works if the decision-making
effort is mutual, that is both the patient & provider contribute to the
trade-off, preferences & decision discussions.
So where are we?
I’m maintaining that the integration of information from public social media
can be an important contribution to clinical workflows for two reasons: it may
provide unique & important information to the diagnosis & treatment
process that has not been previously available & it may serve to more
deeply engage patients in their healthcare decisions because information
provided by them is being used by their provider(s). I’ve also stated that
shared decision making is the most effective model for structuring the
provider-patient interaction. How might this actually work?
The most common
provider workflow for patient interaction today is provider by the electronic
health record system in use. There is no current provision for integrating
external data into this workflow (other than lab, pharmacy & other provider
related data), & there is little motivation by either providers or vendors
to provide such integration. There is, however as previously noted, a lever to
motivate providers – better outcomes. The provider (or one of their staff) is
previewing the patient’s records prior to a scheduled encounter. The system
informs the reviewer that additional information is available from an
identified source. This source could be a PHR or a social media stream that the
patient has posted personal health information to. The information may be a
post from the previous week where the patient described feeling sick or even an
image of a skin rash or other physical symptom. As already stated, this
information is in a separate stream from the EHR data & is not moved from
its source unless the reviewer requests it. The reviewer can look at the
information, decide if it is relevant, & choose to include it in the
overall data package to be available during the encounter. If the reviewer
chooses not to include it, a notification is included that external information
from specified sources was reviewed but not included & the provider has the
option to look at it during the encounter. If the information is included, it
is presented as a separate stream at the beginning of the workflow so as not to
alter the rest of the encounter. It is also stored separately & tagged as
part of a specific encounter, so that it can be recovered as part of the
encounter, but is not managed as part of the EHR data. This could change over
time as such information becomes more accepted & important to diagnosis
& treatment.
There are many
other ways that information from these external sources could be integrated
into provider workflows. They could be part of the practice management workflow
when the appointment is set up, but someone on the clinical staff would have to
review them & the above model might have to be followed at the time of the
encounter so that the most current information is available. Other models would
also be developed through experience as such information is used.
Certain types of
information related to specific practices may be more relevant initially than
others. These information types might include:
- Social media dialogs that reveal a patient’s expectations, attitudes & personal limitations with respect to their healthcare
- Social media dialogs relevant behavioral healthcare
- Dermatological or trauma images taken at the time of injury or presentation.
The types of
information seen as relevant & effective will expand as this data is used
& accepted more.
Of course, there
are issues & constraints related to this model as well. Right up front is
the status of using this type of data for diagnosis & treatment. If a
provider were simply reading a patient’s social media stream & attempting
to treat them on that basis, it appears that they would be in violation of the
HIPAA statutes. I believe that if a provider had consent from the patient (as
with any other personal health information) to use such information, the HIPAA
guidelines would be met (but I could be wrong). Then there is the question of
what constitutes such information. If the relevant or interesting content is
part of a stream that other people are participating in, then the consent is
only good for the patient & not the other participants, however the most
interesting content might be in the interaction that is lost if only a single
person’s contributions are captured. What about individual postings that have
comments from other people, like an image that a patient wants feedback on?
There are many such issues.
Finally, there is
the issue that no systems capable of providing this type of function are
available currently in healthcare. All of the capabilities are present in other
types of systems, but someone would have to build a prototype & pilot this
type of use. Who would do this? Health & Human Services (ONC)? Commerce?
the DoD? the VA? Kaiser Permanente? Partners? Hopefully someone would. I’m
trying to start a pilot (through the RCHN Community Health Foundation) to at
least determine people’s attitudes about the use of social media content in
clinical workflows. Stay tuned.
Coming next:
- A deeper look at analytics in healthcare
- Some opinions on current trends
- &, the Future might even make another guest appearance.
Please also see my
writing for the RCHN Community Health Foundation at: http://www.rchnfoundation.org/?page_id=484
[1]
c.f - Makoul G, Clayman ML. 2006. An Integrative Model of Shared
Decision Making in Medical Encounters. Patient Educ Couns.60:301–12. or Elwyn,
G. et al. 2012. Shared Decision Making: A Model for Clinical Practice. J.Gen’l.
Int. Med. 27(10) 1361-67,
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