Geeta Nayyar, M.D., MBA: It’s clear that technology is one aspect of this, but the harder part is the cultural component. And we heard a little bit about the culture at Mayo Clinic and Atrium Health. How could technology play a role in helping to shift the culture? Because that’s the hardest part. We have the technology. We have all kinds of stuff that can help our doctors get more control, but it’s the cultural shift that needs to work.
Rasu Shrestha, M.D., MBA: It’s interesting, and I think it’s important for us to take a step back and look at some of the big scenes, the dynamics that affect how we use technology to influence what it is that we’re doing in terms of providing care.
For the longest time as we’ve been rolling out EMRs [electronic medical records] in the instantiations that we have today, we’ve been designing those solutions for regulation. And regulation inherently is not bad — it’s there to protect us, it’s there to protect the patient: HIPAA [Health Insurance Portability and Accountability Act] and ICD-9 [International Classification of Diseases, Ninth Revision] and ICD-10 [Tenth Revision] codes and all of that. When do we start designing for empowerment, empowerment of the clinicians and of the patients and all of that? I think designing for empowerment versus regulation is important. Designing for regulations has caused burnout. I think designing for empowerment will cause joy, which was a point that you made earlier.
And I think the other thing we need to look at thematically and from a cultural perspective is how today, we’re inundated with bureaucracy in healthcare. What’s really happening is, as we shift not just the conversations but the way that we’re measuring outcomes and measuring satisfaction, we shift from volume-based healthcare to value-based healthcare. We’re quickly moving from bureaucracy to meritocracy. So rewarding merit, I think, is going to be critical. And all of these instantiations of how culture is shifting will then suddenly influence the direction of how we embrace technology and the design or the redesign of the solutions that we’re using every day.
Geeta Nayyar, M.D., MBA: Those are excellent points. And so much in the health-tech industry, we talk about patient engagement, right? We talk about all kinds of ways and technologies to engage the patients. But ultimately, if we think about technologies that can create physician engagement, the patient engagement aspect is going to follow. So any thoughts on technological innovations or physician engagement that can help shift the culture?
Heather Staples Lavoie: I think it varies, and you actually see a bit of a bifurcation for newly graduated medical students as compared with people who are further along in their career and the methods by which you engage them and their inclination to use technology first versus technology as a burden.
Geeta Nayyar, M.D., MBA: Well, they’re intuitive for some and not as intuitive for others.
Rasu Shrestha, M.D., MBA: So the digital natives, as they graduate from medical school, what’s that going to look like?
Heather Staples Lavoie: Exactly. There are expectations around using fax machines.
Janae Sharp: They’re going to record with Instagram?
Heather Staples Lavoie: Yes.
Geeta Nayyar, M.D., MBA: I know. Someone asked me to send them a fax the other day and I thought, “Are you kidding?”
Rasu Shrestha, M.D., MBA: That’s right.
Heather Staples Lavoie: And for much of the country, that’s exactly the way physicians, physician practices, still communicate.
Janae Sharp: But I wonder about that because everyone thinks the fax is awful, but really it’s an e-fax, and I can take a picture on my phone, sign it on my phone and send a fax on my phone, and get it uploaded into the exact file that I want it at.
Geeta Nayyar, M.D., MBA: So why can’t you consent?
Rasu Shrestha, M.D., MBA: Yes, and what’s worse is that there are companies who come to you and say, “But we’ve got a perfect solution. We can actually PDF the whole thing and put it in our EMR.” Oh my goodness. When will we realize that PDF is not a digital format? My goodness, we cannot mine for the data sufficiently in PDF.
Janae Sharp: Really. If it can translate to Microsoft Word, why can’t we mine PDF?
Rasu Shrestha, M.D., MBA: It’s a struggle — it really is. There are discreet data elements with the technologies that we have at hand, and we’re still struggling with fax machines, and the PDF is only a slightly better solution. We can do better.
Heather Staples Lavoie: Engagement is so individualized. It really is based on what people’s values are, what’s important to them. It’s not just different generationally, but it’s really different from person to person. It’s why it has to come from the top of an organization because it’s going to take a lot of work, it’s a lot of emphasis.
There’s a great reward associated with it. If you actually invest the time and energy, you will have happy physicians, you will have better health outcomes and you will have happier patients. But understanding what’s meaningful to each physician in order to engage them, that’s a necessary component. And so it’s not just the technology solution. I think technology can be an enablement method, but really, it’s actually getting to understand what ticks for each individual physician, what are they looking for and what’s meaningful to them.
Janae Sharp: Can I say something else?
Geeta Nayyar, M.D., MBA: No, you can’t.
Janae Sharp: Well, I’m gonna. A lot of times we talk about how it has to come from the top. And I know in my experience, I wasn’t at the top. And I decided I didn’t care. So I don’t think it has to come from the top. I think physicians can say, “Look, this sucks.” And they can find ways to make their voice heard, whether that’s partnering or something else. One of the greatest technology tools we have is something like social media where you can say, “This isn’t OK,” and they can’t stop looking at you because it’s out there.
Geeta Nayyar, M.D., MBA: Sure. That’s a fantastic point. I think it goes to culture, because to your point, whether it comes from the top or the bottom, it’s about having a culture of being receptive, right?
Janae Sharp: You think I’m from the bottom? I like to say I was in a different place.
Rasu Shrestha, M.D., MBA: I think we’re in general agreement. I would think that what we need to do is to speak up. So whether it’s at the top or the bottom, we can’t shove this under the carpets any more. We have to speak up. We have to haul it out. We have to then understand the specifics of what it is that we can do together collectively to address physician burnout.
Geeta Nayyar, M.D., MBA: I think those are all amazing points, guys. There’s one more closing thing I want to ask all of you. This is ultimately about resources, right? We talked about spending money in PDFs, we talked about spending money on fax machines, and physicians are burned out. And today actually, rightfully so, whether you’re at the middle, the bottom or the top, it shouldn’t matter. What are some quick thoughts on resource allocation and where that fits in here? Because we have the data, we know when we have a shortage of nurses or shortage of doctors on certain floors. So how does resource allocation fit into this?
Rasu Shrestha, M.D., MBA: It’s interesting when you look at hospital operations and the specifics of what you measure around the widgets. And heads in beds, for example, has been a metric that we’ve used for a long time. And as we look at value-based care, that metric is changing. It’s not about heads and beds any more — it really is about how we make sure that we’re able to provide care and get those patients out of the hospital beds as quickly as possible, because that defines the new success.
Now, you overlay that with physician burnout and the things that we’re measuring around physicians. There are still measures in place, so as a radiologist, how we are measured today is by number of studies dictated and report turnaround time. Pure volume-based metrics. And that is just absolutely wrong. I’m not saying that volume-based metrics are going away. What I’m saying is, if we continue to incentivize physicians with those volume-based metrics, we’re going to get more of the same, and that’s not good enough for us.
Heather Staples Lavoie: I agree. The reimbursement system has really dictated a lot of this. There are so many cases where a low acuity patient who might be on blood pressure medication but is well managed could be monitored by a nurse. They don’t have to present for a visit all the time, but yet because of either quality standards or reimbursement, we’re dragging people into the office. It creates a greater burden on the physician. It could be managed better by someone else.
But there hasn’t been reimbursement for some of those types of services in the past, and that’s changing now, whether it’s because of value-based contracts or because CMS [Centers for Medicare & Medicaid Services] is allowing for certain care coordination services or monitoring services now. I think there’s an opportunity for that to change so that not everything has to be done by the physician. Other people can actually manage or monitor, and maybe even to a greater effect if you have social workers who are interacting with patients who may be at home and have transportation barriers. That might result in better outcomes and save the right patients to present to the physician. But much of this has also followed regulation, but it’s also followed reimbursement.
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