The healthcare industry had high hopes that moving to electronic health records (EHRs) would lead to big improvements in safety and efficiency. As to be expected with any major shift in foundational technology, however, efforts to integrate EHRs into the ongoing business activities of delivering health care hit some snags. An effective solution to the problems providers are encountering with EHRs may lie with an emerging new technology: smart point-of-care mobile communication systems (see sidebar below). These new systems meet the need for intuitive, mobile solutions that connect patients and providers, while also tangibly remaining logical and intuitive. But to fully appreciate how powerful this solution might be, it is helpful first to review current conditions.
The Basis for Payment Is Shifting
In years past, hospitals always strived for safety by voluntarily collecting data for internal improvement and risk management. Hospitals were required only to report certain quality-related information to the Centers for Medicare & Medicaid Services (CMS) out of transparency requirements and to participate in electronic reporting programs, mostly without financial repercussions.
Over the past three years, however, CMS has begun basing more payment mechanisms on the patient safety and quality performance of healthcare providers. Two programs in particular, the Hospital-Acquired Condition (HAC) Reduction program and the Hospital Value-Based Purchasing (VBP) program, affect 2.5 percent of a hospital’s CMS payments–and lower payment rates for any claims associated with treating preventable adverse events.a
In addition, CMS has adopted a composite measure developed by the Agency for Healthcare Quality and Research—i.e., Patient Safety for Selected Indicators (PSI-90)—to play a significant role in determining HAC and VBP ratings.b A relatively new metric for CMS, the PSI-90 is a composite score based on the occurrence of eight adverse events, including pressure ulcers and sepsis. CMS’s HAC Reduction program bases 35 percent of its overall score on PSI-90. Hospitals with the highest HAC scores, which indicate a higher rate of the adverse incidents, receive a 1 percent payment reduction for all discharges. For VBP, CMS will reallocate 1.5 percent of its DRG payments to hospitals according to their overall score, 30 percent of which comprises PSI-90 and four other outcome measures.
Hospitals, some of which receive 50 percent or more of their total payments from CMS, cannot afford to ignore their performance on the HAC Reduction and VBP programs. As commercial payers follow CMS’s example and begin basing more of their payment on safety incidents and outcomes, preventing adverse events, eliminating clinical inefficiencies, and improving quality become even more crucial to financial viability.
The Effect of EHRs on Health Delivery
Meanwhile, healthcare provider organizations have been implementing EHRs, with one of the chief goals being to improve safety by delivering actionable data to clinicians at the point of care. All too often, however, EHRs have unintentionally created additional user-experience friction and technology distraction.c A limitation posed by EHRs is that they frequently pull clinicians out of their natural, efficient workflows and inhibit the clinicians’ ability to view and capture patient context holistically. One often can find clinicians sitting in front of computers, hitting refresh buttons while waiting for physician orders to appear or looking up data to support their decisions. What also adds to the inefficiencies of EHRs are the myriad logins and lag times resulting from systems with virtualized platforms. Given these limitations of EHRs, many clinicians still use scraps of paper as reminders or to build context around a patient’s condition.
Clinicians also have created workarounds to adjust for the inefficiencies of their outdated hospital-issued communication tools by using their personal smartphones to more efficiently collaborate with the care team. Recent survey results show that 67 percent of registered nurses use their smartphones for patient care activities, which puts the hospital at risk for HIPAA violations and associated financial penalties.d Patient privacy and security also are put at risk when protected health information (PHI) is shared through a personal smartphone’s unsecured cellular networks.
A smart, intuitive, and reliable point-of-care mobile solution can help meet the challenges posed by EHRs, mobile device proliferation, inefficiencies of legacy communication tools, and the ever-pressing need to improve safety and quality at the point of care. Such technology provides the means to connect clinicians to their patients and care teams, while integrating with existing communications and IT infrastructure—from telephony to EHRs. Regardless of the clinician’s location, a smart point-of-care mobile solution can deliver care-plan context, order notifications, and care team communications onto a single, unified smartphone application. These tools can also be expanded to support clinicians in performing their rounds such as administering medication, collecting lab specimens, verifying mother-baby identification for breast milk feeding, and educating patients.
The result: Data are liberated from the EHR into the hands of clinicians for reliably executed processes and efficient communications. Liberating the data also supports standardized care protocols, improved productivity, as well as clinical-team and patient satisfaction. By fostering consistent use of mobile-enabled protocols and checklists, hospitals and health systems stand to achieve clinical efficiencies and improve quality and safety. Such technology also holds the promise of increased revenue, reduced costs, and improved safety in patient care.
The Effect of EHRs on Workflows
Organizations that have spent millions of dollars on their EHR systems deserve a significant ROI. Consider, for example, that 72 percent of health system executives responding to a 2014 survey reported that their organizations had invested in upgrading their IT systems, yet these executives also reported that the biggest savings they had experienced were due to labor, scheduling, and workflow adjustments.e EHRs, instead of improving productivity, have made clinicians less efficient, forcing organizations to redesign workflows to accommodate the technology.
These executives discovered improvements in efficiency are achieved not just by technology alone, but also by staffing and workflow adjustments that result in less wasteful processes and more productive interprofessional care teams. Moreover, even with redesigned workflows, EHRs continue to pull clinicians away from the bedside.
In fact, it is not unusual for clinicians to spend the end of their shift completing their charting, hours after care is delivered. In one study of nurses in the neonatal intensive care unit, 26 percent reported that they skipped documenting directly after caring for a patient due to interruptions and other issues.f Even worse for patient safety are slips of paper lost in the various tasks and travel of day-to-day operations. For example, a handwritten note to turn a patient every two to six hours or to change a catheter may be lost or forgotten, leading to a potential HAC.
EHR reminders also can be all too easily missed away from the bedside, with a similar potential to result in a HAC, medication error, or unnecessary test. New York-Presbyterian Healthcare System, for example, discovered that by equipping its phlebotomists with a smart point-of-care mobile solution to collect specimens, erroneous or duplicative collections were reduced by 20 percent. The significance of this result is underscored by findings of a Loyola University study, which calculated the average cost of a single misidentified specimen at $712.g Added to this benefit is the avoidance of a negative impact on HCAHPS survey scores due to patient discomfort and anxiety caused by inaccurate test results or repeated unnecessary blood collections.
Furthermore, the potential errors caused by retroactive charting can affect data integrity, which the ECRI Institute recently noted as one of its top 10 patient safety concerns.h Nurses and other clinicians who have the most contact with patients during a hospital stay need to have mobile, efficient tools so they can capture the crucial, granular data at the point of care that may be forgotten or incorrectly recalled during charting conducted hours later. Retroactive charting also leaves physicians, who may be off site when checking on a patient’s status, largely uninformed, impacting care decisions, quality, and safety.
A Focus on Safety and Quality—and Impact on Payment
The organizational struggle between unintended consequences of poor EHR usability and heightened demands for efficient clinical workflows and safety and quality improvement at the point of care are now a matter of financial concern. Strategic conversations concerning these issues are starting to happen at the CFO level. Senior finance executives are sitting with clinical and quality leaders to examine the impact of VBP, the PSI-90, HCAHPS, and other process of care measures. Finance leaders recognize that safety incidences and clinical inefficiencies now hit both the top-line and bottom-line, doubling the previous impact.
Standardized clinical protocols, such as preventing and responding to falls or pressure ulcers, are essential in preventing the adverse events highlighted in the HAC Reduction and VBP programs and improving clinical efficiencies. To ensure standardized protocols are followed, hospitals require a means to help clinicians rely less on their memory or an EHR that is away from the bedside. Clinicians have a compelling need for actionable information on these protocols that is easily accessible when and where they need it. They also need the right mix of communication technology in their work environment to help them collaborate across the care team much more efficiently and effectively.
But for many hospitals, this protocol information is buried in three-ring binders or in the EHR system. Both formats are easily ignored or hard-to-access during a clinician’s busy rounds, and neither helps the clinician respond efficiently or effectively at the point of care. Both offer checkbox solutions instead of meaningfully changing the way care is delivered.
Similarly, many communication tools, even in some technologically advanced hospitals, are inconvenient and inefficient. Clinicians use VoIP phones, pagers, walkie-talkies, overhead paging systems, and the EHR for text messages. None of the existing tools unite the care team around the patient so context is delivered with the text messages, helping inform decisions so they are faster, but also safer and less wasteful. These multiple tools also lack the ability to connect interprofessional care teams, wherever they may be located, so relevant safety or care information that may not be in a chart can be shared efficiently when it is needed.
As a result, clinicians are using their personal smartphones due to their ability to communicate and share contextual information within those messages, uniting the care team. These unsecured smartphones and networks create the potential for the unauthorized disclosure of PHI and penalties of as much as $50,000 per violation.i By contrast, all aspects of smart point-of-care mobile solutions are built on secure communication protocols specifically designed to safeguard sensitive information. Making sure all members of the care team communicate through the designated smart point-of-care mobile solution ensures the protection of PHI.
Mobile Bridges Gaps and Delivers Context
Smart point-of-care mobile solutions can help address inefficient EHR-driven workflows and improve patient safety through better care-team communication and data capture for charting. These tools deliver the data and physician orders from the EHR and enable timely clinical documentation by staff, in addition to the notifications that clinicians need at the point of care to prevent adverse events and drive safe, cost-effective care decisions.
Mobile solutions also enable clinicians to capture data more easily and accurately at the point of care instead of after the round or shift. When all clinicians and data are connected on the same mobile platform, they can quickly determine who is on the patient’s care team and each team member’s role, resulting in better responsiveness in messages between clinicians and to patient calls.
As communication between care teams improves, clinical care protocols become standardized. Mobile solutions bring convenience and responsiveness to the type of short-duration, high-frequency care clinicians deliver at any given moment to help guide physicians through the decision points based on the hospital’s evidence-based guidelines. Necessary variations in care, due to unique patient characteristics, can be easily documented at the point of care within the mobile technology for quality and safety audits. All of the above enable not only safer clinical workflows, but also more efficient and predictable workflows.
Smart point-of-care mobile solutions can unify these crucial data management and communication functions onto a single device. If built on a configurable platform, the tool can also help clinicians administer medication using an embedded scanner for barcoded administration, as well as collecting specimens.
The mobile systems also offer executive leadership a powerful tool for assessing clinician productivity more accurately and effectively—a consideration that 88 percent of the health system executives responding to the previously cited 2014 survey regard as being important for achieving cost savings. With better insight into which times and units clinicians are most productive, scheduling becomes more stable and predictable. Managers can better assign their clinicians to the units and shifts where and when they are most productive and efficient.
This insight, derived from mobile technology, allows hospitals to use fewer costly staffing agency resources, or use them more efficiently. Among executives responding to the survey, 69 percent reported that labor and schedule redesign contributed to savings, and 66 percent similarly attributed savings to core staffing/flex staffing changes. Shifts are more likely to finish on time when charting can be completed by clinicians at the point of care, not at the end of the shift.
When Care Is Standardized, Waste Is Eliminated
As government and commercial payers increasingly move toward bundled payment for providers’ services, providers must become more willing to accept more financial risk for the care they deliver.j
Just as payers use actuarial tables to determine providers’ payment, hospitals can leverage evidence-based, standardized care plans to ensure that costs will remain within the bundled payment limit. To this end, they must analyze every line item including clinician hours required, labs, tests, medication consumed, and supply usage.
When costs are consistently less than the payer’s bundled payment, and outcomes are consistently positive, a provider organization not only becomes more profitable, but also is able to exert greater influence over future value-based compensation programs with payers.
Hoag Orthopedic Institute in Irvine, Calif., for example, is a CMS Five-Star organization that has achieved such outstanding, cost-effective outcomes that its providers are consistently favored by its health insurers in fee-schedule negotiations. Hoag heavily emphasizes care standardization and efficiency and uses smart point-of-care mobile solutions to support its clinicians’ workflows.
This standardization is enabled by liberating data from the EHR and unifying care interprofessional team communications onto a single, mobile platform. Because the intuitive technology operates like the smartphone platforms to which clinicians are already accustomed, adoption is swift, unlike the adoption rates seen with EHRs. Furthermore, training may take only an hour instead of the days or weeks often required for training with EHR implementations.
Best of all, instead of investing more in their EHRs, organizations can leverage these point-of-care mobile solutions to improve workflow efficiency and standardize care protocols for significant safety, financial, and care-quality performance improvements.
Si Luo is president of PatientSafe Solutions, San Diego, and a member of HFMA’s San Diego-Imperial Chapter.