To complement our new report, Delivering the benefits of digital health care , we’re running a blog series exploring how digital information technologies can help to transform health services. The series is a mix of interviews and thought pieces from a range of perspectives including frontline staff, digital practitioners, researchers and others.
We talked to Robert Pearl, CEO of The Permanente Medical Group of US integrated care consortium Kaiser Permanente, on the complicated business of improving quality outcomes while drawing efficiency savings from technology in health care.
Health care technology provides four huge areas of opportunity to improve quality while increasing workforce productivity, each of which can promote different gains and have different requirements for success.
1. Electronic health records (EHR)
The electronic health record is the foundation. It’s what allows you to do everything else so much more efficiently and effectively because you now have the information in a truly integrated system at every point of contact.
It allows you to focus on quality measures at all visits; a good example is an ophthalmologist or dermatologist appointment where the physician, thanks to EHRs, can see the complete record and spot gaps in care. As a result, the patient can not only obtain glasses or have a skin tumour removed, but also have their colon cancer or breast cancer screening ordered or performed. Not only that, but any observations the specialists make – such as a routine blood pressure check – can be noted in the EHR so it is available immediately to the primary care physician or any other physicians who are caring for the patient. This opportunity to have all of this information in the electronic health record is a major advance.
2. Mobile technology
At Kaiser Permanente we have extensive experience with mobile technology. We take care of close to four million people at Permanente Medical Group, have over 8000 physicians, and we make 10 million virtual contacts – more than two per patient per year. Obviously some patients account for a lot of contacts, others less so, but over 70 per cent of our patients have signed up for the mobile application that allows us to preserve their privacy and facilitate virtual medical care.
The downside, from a cost perspective, is that when the technology is available people use it more than they would have used the alternative. We’ve seen a year-on-year increase of about 10 per cent in people sending secure messages or using e-consultation services in some form, but the visit rate is only going down at a rate of one or two per cent. So it actually takes up more physician hours. However, at the same time, it improves patient satisfaction and allows us to make sure there are no care gaps, producing an efficiency of a different type.
3. Video technology
One of the biggest windows of opportunity for productivity saving is going to come from video technology. This is because video can truly replace a patient’s visit with an interaction that takes up less time, and in such a way that they aren’t inconvenienced and don’t have to miss work.
Seventy per cent of what we do in medicine is through taking a patient’s history; which can be done remotely. Likewise, combining voice and video allows us to do a significant amount of urgent care virtually. And we can do the follow-up care after surgery, and provide specialist consultation when the patient is in the primary care physician’s office. So there is a huge amount that we can do with video, particularly when we leverage economies of scale so that one physician provides video services to a very large area. For example, with a lot of rural areas in England, there could potentially be a single specialist physician sitting in a major centre taking care of five or six relatively small towns scattered across the more rural parts of the country.
4. Data and analytics
While we’re very early on in the process, data and analytics have the potential to be incredibly powerful in future.
At Kaiser, we already have an electronic health record for all of our in-patients. Through data and analytics, what we can now do is predict which patients in a regular hospital bed are going to be in the intensive care unit (ICU) two days from now – whether that’s a 20, 40 or 50 per cent chance. What you actually do with those numbers is a different question. In some cases we’ve put the patient into the ICU preventatively: for example, if there is a 60 per cent chance they are going to be there in two days, we would like them there today.
There are more than 2,000 patients in our hospitals every night. Using electronic systems, we are now able to have just a few individuals – nurses and physicians – who can follow all of these patients using these tools and identify which patients are likely to deteriorate. By intervening before the problem develops, we can reduce the chances of a major complication.
We want to use predictive analytics to enable doctors to work smarter. This is going to create major improvements in quality but may also lower costs. In a hospital setting, where everything is so expensive, when we can attack a problem (sepsis is a great example) earlier in the process, we convert what otherwise would be a three-week hospital stay into a three-day stay.
Pushing the boundaries of what we can do with data
This discussion started with one of the least cost-effective technologies today - the electronic health record. It is inefficient because, for the most part, doctors are still using it like a paper record and it simply takes doctors longer to enter into an electronic form than it does to handwrite it. On the other hand, at the end of the rainbow is the predictive analytics, raising the possibility that we will actually be able to use this information to change things in a way that would create a massive cost saving. Not from the primary care doctor’s time, or even the specialist physician’s time, but ultimately from where it is the most expensive: at the hospital level.
People have a tendency to think that systems medicine is in some way less excellent than individual art medicine, but what we are learning in the 21st century is exactly the opposite. There is a scientific answer to most things – at least how we should best treat particular patients – but often physicians don’t act upon it.
That ability to move health care in a way that we can make sure that every patient gets the right thing done every time, would advance medicine, raise quality and lower cost.
At the end of the 20th century, I visited a health facility in Oregon and there was a sign on the wall that said ‘Quality, Service, Cost – pick any two’. My belief in the 21st century is that we can have all three and that the key to having all three is going to be technology.
The views presented in this blog are those of the authors and do not necessarily represent the views of the Nuffield Trust or our partners.
All product and company names mentioned throughout this blog are the trademarks, service marks or trading names of their respective owners, and do not represent endorsements.
Pearl R (2016) ‘In discussion with: Robert Pearl’. Nuffield Trust comment, 18 February 2016. https://www.nuffieldtrust.org.uk/news-item/in-discussion-with-robert-pearl