Tuesday, March 19, 2019

Data-driven and intelligent healthcare processes improve patient outcomes while making the IT increasingly invisible

The next BriefingsDirect intelligent solutions discussion explores how healthcare organizations are using the latest digital technologies to transform patient care and experiences.

When it comes to healthcare, time is of the essence and every second counts, but healthcare is a different game today. Doctors and clinicians, once able to focus exclusively on patients, are now being pulled into administrative tasks that can eat into their capability to deliver care.

To give them back their precious time, innovative healthcare organizations are turning to a new breed of intelligent digital workspace technologies. We are now joined by two leaders who will share their thoughts on how these solutions change the game and help transform healthcare as we know it.

Listen to the podcast. Find it on iTunes. Read a full transcript or download a copy.

Please welcome Mick Murphy, Vice President and Chief Technology Officer at WellSpan Health, and Christian Boucher, Director and Strategist-Evangelist for Healthcare Solutions at Citrix. The interview is moderated by Dana Gardner, Principal Analyst at Interarbor Solutions.

An integrated healthcare system with more than 19,000 employees serving Central Pennsylvania and Northern Maryland, WellSpan Health consists of 1,500 physicians and clinicians, a regional behavioral health organization, a homecare organization, eight respected hospitals and more than 170 patient care locations.

Here are some excerpts:

Gardner: Christian, precision medicine is but one example of emerging trends that target improved patient care, in this case to specifically to treat illnesses with more specialized and direct knowledge. What is it about intelligent workspace solutions that help new approaches, such as precision medicine, deliver more successful outcomes?

Boucher: We investigated precision medicine to better understand how such intricate care was being delivered. Because every individual is different -- they have their own needs, whether on the medication side, the support side, or the genomic side -- physicians and healthcare are beginning to identify better ways to treat patients as a customized experience. This comes not only in the clinical setting, but also when the patients get home. Knowing this helped us formulate our concept of the intelligent workspace.

So, we decided to look at how users consume resources. As an IT organization -- and I supported a healthcare organization for 12 years before joining Citrix -- it was always our role to deliver resources to our users and anticipate how they needed to consume them. It’s not enough to define how they utilize those resources, but to identify how and when they need to access them, and then to make it as simple and seamless as possible.

With the intelligent workspace we are looking to deliver that customized experience to not only the organizations that deploy our solutions, but also to the users who are consuming them. That means being able to understand how and where the doctors and nurses are consuming resources and being able to customize that experience in real-time using our analytics engines and machine learning (ML). This allows us to preemptively deliver computing resources, applications, and data in real-time.

For example, when it comes to walking into a clinic, I can understand through our analytics engine that we will need for this specific clinic to utilize three applications. So before that patient walks in, we can have those apps spinning up in the background. That helps minimize the time to actual access.

Every minute we can subtract from a technology interaction is another minute we can give back to our clinicians to work with the patients and spend direct healthcare time with them.

Gardner: Understanding the context and the specific patient in more detail requires bringing together a lot of assets and resources on the back end. But doing so proactively can be powerful and ultimately reduces the complexity for the people on the front lines.

Mick, WellSpan Health has been out front on seeking digital workspace technology for such better patient outcomes. What were some of the challenges you faced? Why did you need to change the way things were?

IT increases doctor-patient interaction

Murphy: There are a couple of things that drive us. One is productivity and giving time back to clinicians so that they can focus on patients. There is a lot of value in bringing more information to the clinical space. The challenge is that the physicians and nurses can end up interacting more with computers than with the patients.

We don’t think about this in minutes, but in 9-second increments. That may sound a little crazy, but when we talk about a 15-minute visit with a primary care doctor, that’s 900 seconds. And if you think about 9 seconds, that’s 1 percent of that visit.

We are looking to give back multiple percentage points of such a visit so that the physician is not interacting with the computer, they are interacting directly with the patient. They should be able to quickly get the information they need from the medical record and then swivel back and focus directly on the patient.

Gardner: It’s ironic that you have to rely on digital technology and integration -- pulling together disparate resources and assets -- in order to then move past interacting with the computers.

Murphy: Optimally the technology fades into the background. Many of us in technology may like to have the attention, but at the end of the day if the technology just works, that's really what we are striving for.

We want to make sure that as soon as a physician wants something -- they get it. Part of that requires the ability to quickly get into the medical record, for example. With the digital workspace, an emphasis for us was improve on our old systems. We were at 38 seconds to get to the medical records, but we have been able to cut that to under 4 seconds.
How the Right Technology
Improves Patient Care and
Helps Save Lives
This gets back to what Christian was talking about. We know when a physician walks into an exam room that they are going to need to get into the medical records. So we spin up a Citrix session in advance. We have already connected to the electronic health records (EHRs). All we are waiting for is the person to walk in the door. And as soon as they drop their ID badge onto a reader they are quickly and securely into that electronic medical record. They don’t spend any time doing searches, and whatever applications are needed to run are ready for them.

Gardner: Christian, having technology in the background, anticipating needs, operating in the context of a process -- this is all complex. But the better you do it, the better the outcome in terms of the speed and the access to the right information at the right time.

What goes on in the background to make these outcomes better for the interactions between the physicians, clinicians, and patients?

Boucher: For years, IT has worked with physicians and clinicians to identify ways to increase productivity and give time back to focus more on patient care. What we do is leverage newer technologies. We use artificial intelligence (AI),  ML, and analytics and drill down deeper into what is happening -- and not only on a generic physician workflow.

It can’t just be generic. There may be 20 doctors at a hospital, but they all work differently. They all have preferences in how they consume information, and they perform at different levels, depending on the technology they interact with. Some doctors want to work with tablets and jump from one screen to the next depending upon their specific workflow. Others are more comfortable working with full-on laptops or working on a desktop.

We have to understand that and deliver an experience that each clinician can decide is best-suited for their specific work style. This is really key. If you go from one floor to another in a hospital and watch how nurses work differently -- from the emergency room to the neonatal intensive care unit (NICU) -- the workflows are considerably different.

Not only do we have to deliver those key applications, we have to be mindful of how each of those different groups interacts with the technologies. It's not just applications. It's not just accessing the health record. It's hardware, software, and location.

We have to be able to not only deliver those experiences but predict in real-time how they will be consumed to expedite the processes for them to get back into the patient-focused arena.

Work outside the walls

Murphy: That’s a great point. You mentioned tablets. I don’t know what it is about physicians, but a lot of their kids seem to swim. So a lot of our doctors spend time at swim meets. And if you are on-call and are at a swim meet, you have a lot of time when your child is not in the pool. We wanted to give them secure access [to work while at such a location].

It's really important, of course, that we make sure that medical records are private and secure. We are now able to say to our physicians, “Hey, grab your tablet, take it with you to the swim meet. You will be able to stay at the swim meet if you get a call or you get paged. You will be able to pop out that tablet, access the medical records – and all of that access stays inside of our data center.”

All they are looking at is a pretty picture of what's going on inside the data center at that point. And so that prescription refill that’s urgent, they are able to handle that there without having to leave and take time away from their kids.

We are able to improve the quality of life for our physicians because they are under intense pressure with healthcare the way it is today.

Boucher: I agree with that. As we look at how work is being done, there is no predefined workspace anymore -- especially in healthcare where you have these on-call physicians.
Look at business operations. We are able to offset internal resources for billing. The work does not just get done in the hospital anymore. We are looking at ways to extend that same secure delivery of apps and data outside the four walls.

Just look at business operations as well. We are able to offset internal resources for billing. The work does not just get done in the hospital anymore. We are looking for ways to extend that same secure delivery of applications and data outside the four walls, especially if you have 19 hospitals.

As you find leverage points for organizations to be able to attract resources that may not fall inside the hospital walls, it’s key for us to be more flexible in how we can allow organizations to deliver those resources outside those walls.

Gardner: Christian, you nailed it when you talked about how adoption is essential. Mick, how have digital workspace solutions helped people use these apps? What are the adoption patterns now that you can give flexibility and customize the experience?

Faster workflow equals healthier data

Murphy: Our adoptions are pretty strong. I will be clear, it's required that you interact with electronic health records. There isn't really an option to opt out. But what we have seen is that by making this more effective and faster, we have seen better compliance with things like securing workstations. Going back to privacy, we want to make sure that that electronic health data is protected.

And if it takes me too long to get back into a work context, well, then I may be tempted to not lock that workstation when I step away for just a moment. And then that moment can become an extended period and that would be dangerous for us. Knowing that I am going to get back to where I was in less than four seconds -- and I am not even going to have to do anything other than touch my badge to get there, -- means we see that folks secure their workstations with great frequency. So we feel like we are safer than we were. That’s a major improvement.

Gardner: Mick, tell us more about the way you use workspaces to allow people to authenticate easily regardless of where they are.

Murphy: We have combined a couple of technologies. We use smart badges with a localized reader, with the readers scattered about for the folks who need to touch multiple workstations.


So myself as an executive, for example, I can log into one machine by typing in my password. But for clinicians going from place to place, we have them login once a day and then as long as they are retaining their badge and they are getting back in. All they have to do is touch their badge to a reader and it drops them right back into their workspace.

Gardner: We began our conversation talking about precision medicine, but there are some other healthcare trends afoot now, too. Transparency about the financial side of healthcare interactions is increasingly coming into play, for example.

We have new kinds of copays and coinsurance, and it’s complex. Physicians and clinicians are being asked more to be part of the financial discussion with patients. That requires a whole new level of integration and back-end work to make that information available in these useful tools.

Taking care of business

Murphy: That is a big challenge. It's something we are investing in. Already we are extending our website to allow patients to get on and say, “Hey, what’s this going to cost?” What the person really wants to know is, “What are my out-of-pocket costs going to be?” And that depends on that individual.

We haven’t automated that yet end-to-end, but we have created a place where a patient can come on and say, “Hey, this is what I am going to need to have done. Can you tell me what it's going to cost?”

We actually can turn that back around [with answers]. We have to get a human being involved, but we make that available either by phone or through our website.

Gardner: Christian, we are seeing that the digital experience and the workspace experience in the healthcare process are now being directed back to the patient, for patient experience and digital experience benefits. Is the intelligent workspace approach that provider organizations like WellSpan are using putting them in an advantageous position to extend the digital experience to the patient -- wherever they are -- as well as to clinicians and physicians?

Boucher: In some scenarios we have seen some of our customers extend some of Citrix’s resources outside to customers. A lot of electronic health records now include patient portals as part of their ecosystem. We see a lot of customers leveraging that side of the house for electronic health records.
We understand that regardless of the industry, the finance side and he back-office side play a major role in any organization's offerings. It's just as important to be able to get paid for something as it is to deliver care or any resource.

We understand that regardless of the industry, the finance side and the back-office side play a major role in any organization’s offerings. It's just as important to be able to get paid for something as it is to deliver care or deliver any resources that your organization may deliver.

So one of the key aspects for us was understanding how the workspace approach transforms over the next year. Some of the things we are doing on our end is to look at those extended workflows.

We made an acquisition in the last six months, a software company, [Sapho], that essentially creates micro apps. What that really means is we may have processes on ancillary systems, they could be Software as a service (SaaS) -based, they could be web-based applications, they could be on-premises installations of old client/server technologies. But this technology allows us to create micro experiences within the application.

So just say a process for verifying billing takes seven steps, and you have to login to a system, and you have to navigate through menus, and then you get to the point where you can hit a button to say, “Okay, this is going to work.”

What we have done is take that entire workflow -- maybe it’s 10 clicks, plus a password -- and create a micro app that goes through that entire process and gives you a prompt to do it all in one or two steps.

So every application that we can integrate to -- and there are 150 or so – we can take those workflows, which in some cases can take five minutes to walk-through and turn it into a 30-second interaction with [the Sapho] technology. Our goal is to look beyond just general workflows and be able to extend that out into these ancillary programs, where you may have these kinds of normal everyday activities that don't need to take as long as they do and simplify that process for our end users to really optimize their workflows during the day.

Gardner: This sounds like moving in a direction of simplifying process, using software robots and as a way of automating things, taking the time and compressing it, and simplifying things -- all at the same time.

Murphy: It’s fascinating. It sounds like a great direction. We are completely transparent, and that’s a future for us. It sounds like I need to get together with Christian after this interview.

Gardner: Let’s revisit the idea of security and compliance. Regulations are always there, data sharing is paramount, but protecting that data can be a guard rail or a limiter in how well you can share information.

Mick, how are you able to take that patient experience with the clinician and enrich it with all the data and resources you can regardless of whether they are at the pool, at home, on the road, and yet at the same time have compliance and feel confident about your posture when it comes to risk?

Access control brings security, compliance

Murphy: We feel pretty good about this for a couple of reasons. One is, as I mentioned, the application is still running in our data center. The the next question is, “Well, who can get access to that?”

One way is strong passwords, but as we all know with phishing those can be compromised. So we have gone with multifactor authentication. We feel pretty good about remote access, and once you have access we are not letting you pull stuff down onto your local device. You are just seeing what’s on the screen, but you are not pulling files down or anything of that nature. So, we have a lot of confidence in that approach.


Boucher: Security is always a moving target, and there may be certain situations when I access technology and I have full access to do what I please. I can copy and paste out of applications, I can screenshot, and I may be able to print specific records. But there may be times within that same workflow -- but a different work style -- where I may be remote-accessing technologies and those security parameters change in real-time.

As an organization, I don’t feel comfortable allowing user X to be able to print patient records when they are not on a trusted network, or they are working from home, or on an unknown device.

So we at Citrix understand those changing factors and understanding that our border now is the Internet. If we are allowing access from home, we are now extending our resources out to that, out to the Internet. So it really gives us a lot more to think about.

We have built into our solutions granular control that uses ML and analytics solutions. When you access something from inside the office, you have a certain amount of privileges as the end user. But as soon as you extend out that same access outside of the organization, in real-time we can flip those permissions and stop allowing users to print or screenshot or copy and paste between applications.
Digitally Enhanced Precision Medicine
Delivers Patient-Specific Care to
Treat Illness and Cure Diseases
And that’s invisible to the end-user. It all happens in the back-end in real-time. Security is something that we take extremely seriously at Citrix, and we understand that our customers do as well. So, giving them those controls allows them to be a lot more nimble in how they deploy solutions.

Murphy: I agree with that. Another thing that we like to do is have technology control and help people be safe. A lot of this isn’t about the bad actor, it’s about somebody who’s just trying to do the right thing -- but they don’t realize the risk that they are taking. We like to put in technology safeguards. For example, if you are working at home, you are going to have some guardrails around you that are tighter than the guardrails when you are standing in our hospital.

Gardner: Let’s revisit one of our core premises, which is the notion of giving time back to the clinicians, to the physicians, to improve the patient experience and outcomes. Do you have other examples of intelligent and digital workspace solutions that help give time back? Are there other ways that you’re seeing the improvement in the quality of care and the attention span that can be directed at that patient and their situation?

The top of your license

Murphy: We talk a lot in healthcare about working at the top of your license. We try and push tasks to the least skill level needed in order to do something.

When you come in for a visit, rather than having the physician look up your record, we have the medical assistant that rooms you and asks why you are there. They open the record, they ask you a few questions. They get all that in place. Then they secure the workstation. So it’s locked when the physician walks in and they drop their badge and get right in to the electronic medical record in four seconds.

That doctor can then immediately turn to you and say, “Hey, how are you doing today? What brings you in?” And they can just go right into the care conversation. The technology tees everything up so that the focus is on the patient.

Gardner: I appreciate that because the last thing I want to do is fill out another blank clipboard, telling them my name, my age, date of birth, and the fact that I had my appendix out in 1984. I don’t want to do that four times in a day. It’s so great to know that the information is going to follow me across the process.

Murphy: And, Dana, you are better than me, because I had a tonsillectomy in ‘82, ‘83, ‘84? It depends on which time I answered the survey correctly, right?

All systems go with spatial computing 

Boucher: As we look forward a few years, that tighter integration between the technologies and our clinicians is going to become more intertwined. We will start talking about spatial computing and these new [augmented reality] interfaces between doctors and health records systems or ambulatory systems. Spatial computing can become more of a real-time factor in how care is delivered.

And these are just some of the things we are talking about in our labs, in better understanding how workflows are created. But imagine being able to walk into a room with no more than a smart watch on my wrist that’s essentially carrying my passport and being able to utilize proximity-based authentication into those systems and interact with technology without having to login and do all the multifactor authentications.

And then take a step further by having these interfaces between the technology in the room, the electronic records, and your bed-flow systems. So as soon as I walk into a room, I no longer have to navigate within the EHR to find out which patient is in the room. By them being in the room and interfacing with bed flow, or having a smart patient ID badge, I can automatically navigate to that patient in real-time.
As soon as I walk into the room, I no longer have to navigate within the EHR to find out which patient is in the room. By them being in the room and interfacing with the bed flow, or having a smart ID badge, I can navigate to the patient in real time.

In reality, I am removing all of the administrative tasks from a clinician workflow. Whether it’s Internet of things (IoT)-based devices, or smart devices in rooms, they will help complete half of that workflow for you before you even step in.

Those are some of the things we look at for our intelligent workspace in our micro app design and our interfaces across different applications. Those are the kind of ways that we see our solutions being able to help clinicians and organizations deliver better care.

Gardner: And there is going to be ever-more data. It’s always increasing, whether it’s genomic information, a smart device that picks up tracking information about an individual’s health, or more from population information across different types of diseases and the protocols for addressing them.

Mick, we are facing more complexity, more data, and more information. That’s great because it can help us do better things in medicine. But it also needs to be managed because it can be overwhelming.

What steps should we be taking along the way so that information becomes useful and actionable rather than overwhelming?

AI as medical assistant

Murphy: This is a real opportunity for AI around an actual smart clinical assistant. So something that’s helping comb through all the data. There’s genomic data, drug-drug interaction data, and we need to identify what’s most important to get that human judgment teed up.

These are the things that I think you should look at versus, “Oh, here is all the possible things you could look at.” Instead we want, “Here are the things that you should really focus on,” or that seem most relevant. So really using computing to assist clinicians rather than tell them what to do. But at least help them with where to focus.

Gardner: Christian, where would that AI exist? Is that something we’re going to be putting into the doctor’s office, or is that going to be something in a cloud or data center? How does AI manifest itself to accomplish what Mick just described?

Boucher: AI leverages intense computing power, so we are talking about significant IT resources internally. While we do see some organizations trying to bring quantum computing-based solutions into their organization and leveraging that, what I see is probably more of a hosted solution at this point. That’s because of the expense but also because of the technology, of when you start talking about distributed computing and being able to leverage multiple input solutions.

If you talk about an Epic or Cerner, I’m sure that they are working on technologies like that within their own solutions -- or at least that allow their information to be shared within that.

I think we’re in the infancy of that AI trend. But we will see more-and-more technology play a factor in that. We could see some organizations partnering together to build out solutions. It’s hard to say at this point, but we know there is a lot of traction right now and unfortunately, they are mostly high-tech companies trying to leverage their algorithms and their solutions to deliver that, which at some point, I would guarantee that they’ll be mass produced and ready for purchase.

Murphy: AI could be everything from learning to just applying rules. I might not classify applying rules as AI, but I would say it’s rudimentary AI. For example, we have a rule set, an algorithm for sepsis. It enables us to monitor a variety of things about a patient -- vital signs, lab results, and various data points that are difficult for any one human to be looking at across the entire set of patients in our hospitals at any given time.
Learn How to Build
An Intelligent Workspace
Infrastructure and Culture
So we have a computer watching that. And when certain criteria are met in this algorithm, it reports to a centralized team staffed with nurses. The nurses can then look at that individual patient and say, “Does this look like a false alarm or does this look like something that we really need to pursue?” And based off of that, they send someone to the bedside.

We’ve had dramatic improvements with sepsis. So there are some really easy technical things to do -- but you have to engage with them, with human beings, to get the team involved and make that happen.

Gardner: The intelligent digital workspaces aren’t just helping cut time, they are going to be the front end to help coordinate some of these advanced services that are coming down that can have a really significant impact on the quality of care and also the cost of case, so that’s very exciting.

Listen to the podcast. Find it on iTunes. Read a full transcript or download a copy. Sponsor: Citrix Systems.

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