Shorr and bria innovation at the point-of-care rethinking the doctor-patient encounter

1Please excuse me. Someone else needs my attention.
Confidential & Proprietary. All rights reserved to Rover Technologies, LLC.
1

Innovation at the Point-of-Care:
Rethinking the Doctor-Patient
Encounter
Oct 1, 2013
William Bria, MD
President, AMDIS
Greg Shorr, MD
CMIO, Rover Technologies

Toll, E The Cost of Technology JAMA 307:2497 (2012)
3

The Patient Experience
is always tied to the
User Experience
PX UX
Meaningful Use
vs.
Meaningful Provider-patient Interaction
4

5
5

6
6

7
Patient vs. iPatient
Abraham Verghese, MD
7

Rounds vs. iRounds
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Work Habits of the 21st-Century Intern
Block L et al. J Gen Intern Med 2013 Aug
Documentation
= 40%
(Same as in
1989)
Direct Patient
Care = 40%
(20% in 1989)
9

11

Clinical Implications of Empathy
and Interpersonal Communication
•Improved Patient Satisfaction
Physician empathy and listening: associations with patient satisfaction
and autonomy
Pollak, KI et al J Am Board Fam Med. 2011 Nov-Dec;24(6):665-72.
•Improved Compliance
The Effects of Physician Empathy on Patient Satisfaction and Compliance
Sung, SK et al Eval Health Prof September 2004 27: 237-251
•Improved Outcomes
The relationship between physician empathy and disease complications
Del Canale, S et al. Acad Med 2012 Sep;87(9):1243-9.
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“The VA’s Center for Innovation (VACI) identifies, tests, and evaluates innovative
solutions to help VA better serve Veterans. We develop programs that nurture
innovation and create an environment where informed risk taking and progressive
thinking are rewarded.”
13
VA Innovation project: #5201
“Technology-Enhanced Digital Documentation”
Re-imagine the way clinical information is
managed at the point of service

2012 VHA Innovation Project #5021
• The project was conceived by Dr. Jorge Ferrer who
enlisted Rover Technologies to build and test the
solution
• Voted #20 out of 3,841 VAi2 submissions in 2012
• The project was reviewed and signed off by the VA
leadership including Drs. Petzel and Cullen
• Development will be completed in the VA Sandbox
under the supervision of the VA’s Technical
Director/Sr. Technologist, Bill Cerniuk.
• Deliverables will be tested in VA Usability Labs
14Confidential & Proprietary. All rights reserved to Rover Technologies, LLC.
14

Rover’s Innovation
• Objective: Fundamentally Improve the User
Experience (UX) and Patient Experience (PX) at
the Point of Care
• Strategy: Employ disruptive technology to
overcome the intransigence of the UX found on
the current generation of clinical workstations
• Primary Tactic: Take a form-based approach to
digital documentation that emphasizes the
fundamentals of reading and writing
15

First Principles
• What is the primary clinical purpose of
the EHR?
– “Tell the Patients Story”
• What is the purpose of clinical
documentation?
– “Fill in knowledge gaps”
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Solution #1: The Story
• Encounter preparation is essential
• When a provider walks into the exam
room, he should look like a genius
– Know the patient as a person
– Know the relevant clinical history
• The only way to accomplish this is for the
provider to review the patient’s “story”
before the encounter
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The quality of the story is the single most
important determinant of the quality of
clinical decision making.
18

SUBJECTIVE: The patient is a 66-year-old female who
presents to the clinic today for a five-month recheck on her
type II diabetes mellitus, as well as hypertension. While
here she had a couple of other issues as well. She stated
that she has been having some right shoulder pain. She
denies any injury but certain range of motion does cause it
to hurt. No weakness, numbness or tingling. As far as her
diabetes she states that she only checks her blood sugars
in the morning and those have all been ranging less than
100. She has not been checking any two hours after
meals. Her blood pressures when she does check them
have been running normal as well but she does not have
any record of these present with her. No other issues or
concerns. Upon review of her chart it did show that she
had a benign breast biopsy done back on 06/11/04 and
was told to have a repeat mammogram in six months but
she has never had that done so she is needing to have this
done as well.
ALLERGIES: None.
MEDICATIONS: She is on Hyzaar 50/12.5 one-half p.o.
daily, coated aspirin daily, lovastatin 40 mg one-half tab
p.o. daily, multivitamin daily, metformin 500 mg one tab
p.o. b.i.d.; however, she has been skipping her second
dose during the day.
SOCIAL HISTORY: She is a nonsmoker.
REVIEW OF SYSTEMS: As noted above.
OBJECTIVE:
Vital Signs: Temperature: 98.2. Pulse: 64. Respirations:
16. Blood pressure: 110/56. Weight: 169.
General: Alert and oriented x 3. No acute distress noted.
Neck: No lymphadenopathy, thyromegaly, JVD or bruits.
Lungs: Clear to auscultation.
Heart: Regular rate and rhythm without murmur or gallops
present.
Breasts: Exam performed with a female nurse present.
The breasts do have some scars present underneath
them bilaterally from prior breast reduction surgery.
There is no axillary adenopathy or tenderness. Breasts
appear to be symmetric. There was no nipple discharge
or retraction. Upon palpation there were no palpable
lumps or bumps and no palpable discharge.
Musculoskeletal: She did have full range of motion of her
shoulders. She did have tenderness upon palpation over
the right bicipital tendon. There is no swelling, crepitus or
discoloration noted.
MEDICAL DECISION MAKING: Most recent hemoglobin
A1c was 5.6% back in October 2004. Most recent lipid
checks were obtained back in July 2004. We have not
had this checked since that time.
ASSESSMENT:
1. Type II diabetes mellitus.
2. Hypertension.
3. Right shoulder pain.
4. Hyperlipidemia.
PLAN:
1. She is going to go to lab to obtain a hemoglobin A1c,
BMP, lipids, CPK, liver enzymes and quantitative
microalbumin.
2. We are going to set her up for a diagnostic bilateral
mammogram due to a history of abnormal mammogram
in the past which subsequently showed a benign breast
cyst.
3. I told her for her shoulder to take ibuprofen 600 mg
three times daily with her meals for a minimum of the
next one week.
4. She is going to follow up in the clinic in three months
for a complete comprehensive examination. If any
questions, concerns or problems arise between now and
then she should let us know.
Confidential & Proprietary. All rights reserved to Rover Technologies, LLC 19

Storytelling Technology: Automated
Document Assembly
• Turn structured data into unstructured data
• Scenario-specific content dynamically generated at the
time of service
• Transform a “note-oriented” EHR into a “story-oriented”
EHR
• Reduces the intrusive, time-consuming burden of
navigation and thereby facilitates meaninful provider
patient interaction
21

Stories
• What is the best time to read the
story?
• Who provides the content; i.e., who
fills in the knowledge gaps?
• Who writes the story?
• Who is the recipient of the story?
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Solution #2: An “Ad Hoc UX”
• Dynamically generated at the point of service
• Unique – intended for a single use (disposable)
• Comfortable
– Adequate amount of real estate
– Essential information on the surface
At the point of service, the focus should be on
1. Interpersonal communication
2. Observation
3. Filling in scenario-specific knowledge gaps –
not formal documentation
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• Encompasses a variety of input modalities:
• Ink is recognized; i.e. converted to
actionable information (e.g., ASCI text)
• This technology is uniquely suited for point
of care documentation.
Enabling Technology: Digital “Ink”
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– Digital pen and paper
– Regular pen and paper
– Tablet PC and Stylus
– Streaming voice recording
– Gestures (e.g., LEAP and
Kinnect

Scratch notes
Drawings and signatures
Check boxes
Streaming Dictation
Workstation control
Workflow control
Long handwritten notes
Digital Writing
at the Point of Care
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Standard pen
Digital pen
Stylus
Voice recorder

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X X
X
X
X
X
X
During
sleep
X
X
W
W
W
WR R
R
R D
D
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Workstation Integration
X
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