Creating an Integrated Healthcare Ecosystem Through Mobile Communication Technology
Healthcare delivery is a highly mobile activity: Physicians, nurses, and ancillary care staff are constantly on the move. To communicate and access the data they need to deliver safe and effective care, providers often must do even more walking, usually to a computer workstation, telephone, or hallway, but nearly always further away from the patient.
This constant, often unproductive, movement occurs because the workflows and systems in today’s healthcare environment in all too many cases were neither developed from a holistic standpoint nor optimized for the increasingly complex phases and treatments a patient undergoes in a typical hospital stay. Healthcare finance professionals understand the costs of this nonproductive mobility: Longer care delays, slower patient throughput, fewer patients treated per day, increased time spent on nonclinical tasks, growing patient dissatisfaction, and potential medical errors cost hospitals and health systems millions of dollars a year.
An effective means for addressing this problem is available today in smartphone technology, which can enable providers and administrators to optimize their time and perform their daily tasks more efficiently. With their rapidly advancing sophistication and speed, smartphones present myriad opportunities to improve the response time and efficiency of clinical communication and collaboration across an enterprise. Adoption of this technology requires, however, that providers undertake the often complex task of creating an integrated healthcare ecosystem.
The Costs of Miscommunication and Inefficiency
There are numerous examples of how process inefficiencies contribute to hospital and health system spending. In particular, the emergency department (ED) can be a breeding ground for inefficiency due to the inherent unpredictable nature of the environment. Those variabilities were analyzed across four major institutions in which the average non-fixed costs in an ED visit were found to range from $150 to $638 per patient. a More efficient mobile communication and processes can keep those marginal costs lower by eliminating wasted tests, treatments, and provider time, and even by diverting patients to more appropriate care settings, such as physician practices or behavioral health clinics.
Consult requests are another example of how inefficient communication leads to greater costs. When on-call specialists do not, or cannot, respond to emergency physicians’ consult requests, patients can spend hours waiting in the ED or hospital bed, unnecessarily driving up costs for patient, provider, and payer. Lake Wales Medical Center, a 160-bed community hospital in Florida, decreased its consult time request delays, on average, by nearly 75 percent by using more integrated, mobile-focused clinical communication. Gastroenterologist consult requests, for example, decreased from up to 46 hours to just four hours. Requests to pulmonologists that took as long as five hours were reduced to 38 minutes. With these faster response times, average length of stay and patient wait times in the ED are decreasing, contributing to greater patient satisfaction.
However, no other type of error is as costly as one that results in patient harm. Communication failures were identified in 30 percent of malpractice cases filed from 2009 through 2013, according to a report issued in 2015 by Boston-based CRICO Strategies. b This finding is not surprising considering the antiquated methods such as phone tag, pagers, answering services, and handwritten notes still in use by physicians. Court judgements and settlements, the psychological effects on staff, and reputational costs to an organization can be significant. For example, the CRICO report also notes that these miscommunications resulted in $1.7 billion in payments to plaintiffs.
Further, the HIPAA Security Rule generally forbids most types of short message service (SMS) or “texting” applications native to smartphones to share protected health information. Although hospitals therefore often have policies restricting the use of SMS for patient care, physicians and nurses may disregard the HIPAA rule and the policies and use their mobile devices anyway in the interest of efficiency. This practice poses a significant risk considering that HIPAA violations penalties can range from as little as $100 per violation to as much as $1.5 million, depending on findings of an investigation by the U.S. Department of Health and Human Services’ Office for Civil Rights. c
An Integrated Healthcare Ecosystem Workflow in Action
The good news for hospitals and health systems is that most, if not all, of the pieces are in place to begin using smartphones to create an integrated ecosystem approach to care delivery. Organizations already have electronic health records (EHRs); nurse call systems; admission, discharge, and transfer (ADT) feeds; picture archive and communication systems (PACS); and other platforms to facilitate clinician collaboration. The next step is to seamlessly integrate such systems and platforms to make data and images accessible inside and outside the enterprise.
Once an integrated healthcare ecosystem has been forged, processes that previously consumed hours or days can be significantly shortened. Consider, for example, in the case of a typical ED visit—involving a man who called 911 with chest pain, which he described as 10 out of 10 on the pain scale—how much more efficiently and proactively transitions and communication could flow with each step between different care venues and across numerous specialties leveraging the new approach versus the old approach.
Step 1: Obtain EKG results. Previously, the emergency medical technician (EMT) would perform an EKG at the patient’s home, call the hospital, and wait on hold to speak to the attending physician, who would need to wait until the EKG arrives at the hospital to view full results.
Under the new smartphone-enabled approach, the EMT photographs the results, and securely sends images to the ED with a message indicating a likely ST-elevation myocardial infarction.
Step 2: Assemble the “heart team.”With the old approach, the attending physician likely will have spent several minutes trying to correctly identify and contact his “heart team,” searching white boards, call sheets, directories, and scheduling systems. As a result, different members of the ED staff would experience interruptions at different times, and team members then would likely respond at different times, through different methods.
Under the new approach, upon receipt of the message, ED staff activate a designated “heart team” through the smartphone-based platform. The care team is automatically grouped through the messaging function so all team members can view communications, data, and imaging and share input in one place.
Step 3: Prepare for the patient’s arrival at the hospital so care can be immediately initiated. Under the old approach, even after the patient had arrived at the hospital, the care team likely would still be awaiting responses from its members and might still be attempting to determine availability of radiology, pharmacy, transportation, and other members of the ancillary care team, requiring the patient to wait still longer to receive care.
The smartphone approach allows the hospital, nurses, and an ED physician to be assigned and the ancillary care team activated—including lab, imaging, pharmacy, transportation, and catheterization lab. Then, when the patient arrives, the ED physician signs the orders and care begins: blood draw, chest X-ray, an EKG for the assigned cardiology team, heparin preparation, and transportation ready at the bedside.
Step 4: Determine the most appropriate intervention. All too often in the old way of doing things, the on-call interventional cardiologist would need to wait by a fax machine or rush to the hospital to view test results and images and decide on the safest and most effective intervention.Under the smartphone-enabled approach, the physician reviews all results, including the chest X-ray captured in the PACS, through the smartphone-based platform, and meets the patient in the catheterization lab.
Step 5: Initiate the surgical intervention. Under the previous approach, once the care team had determined the proper surgical intervention, another search of the directory and scheduling systems would need to be undertaken to find the available surgical team members, taking even more time. Meanwhile, other physicians, providers, and ancillary team members would await orders, adding to hospital labor costs and impacting other patients’ care timeliness and satisfaction.
Under the new approach, with the surgical team having been notified through the clinical communication platform of the patient’s arrival and the room prepared, angioplasty is performed.
Thanks to the integrated clinical communication platform, this entire emergency care episode would consume approximately 90 minutes, compared with hours of waiting for messages to be returned, test results to be reviewed, and the entire care team to be updated on the patient’s status. Not only are time and costs saved through fewer care delays, but also, most important, a crucial care intervention occurs as soon as possible, potentially saving a patient’s life.
Making the transition to an integrated healthcare ecosystem requires a governance team of key stakeholders including multiple representatives from the leadership and executive team. Recruiting leaders from physician staff, nursing, and IT is essential because they will see the greatest impact of the transition, while other departments, such as compliance and finance, should be involved. Having these stakeholders clearly define the goals of the transition with metrics for each objective is essential. This group should meet frequently at the onset and then several times throughout the year to promote and facilitate effective use of new systems. To minimize the cost of the transition, this governance committee and its subgroups should draft implementation plans for the clinical communication platform and diagram the associated workflows by top-priority departments.
To further control costs, organizations should perform due diligence on any potential technology to ensure it is fully interoperable with existing platforms. Cloud-based technology that uses a preconfigured application programming interface can connect to systems such as the EHR, nurse call, ADT, PACS, and scheduling for instant alerting and information. Optimizing data and image access for providers through their mobile devices builds trust in the platform, thereby securing long-term adoption, incorporation into daily workflows, and ROI.
Education and training are crucial. Providers may be resistant to using new technology because of their comfort with using the native applications of their own mobile devices. Organizations can obtain buy-in by showing providers how efficiently they can securely collaborate across care teams, receive automated notifications for results and other system-based data, share data and images, and advance patient care.
Also required will be training across the enterprise on the providers’ schedules and locations. Training should start with leaders who recognize that the organization’s legacy clinical communication methods are inefficient and costly, and contribute to medical errors and poorer outcomes. As leaders are trained, they can either serve as instructors or encourage colleagues to learn about the technology and how it can reduce their burden while improving the quality of care they deliver.
Improved Efficiency and Quality of Care
Establishing an integrated, mobile healthcare ecosystem is a new concept, but many healthcare organizations already are experiencing the rewards of their transformation. For example, Waterbury Hospital, a 357-bed midsized community and teaching hospital in Waterbury, Conn., saw an opportunity to reduce care delays and length of stay by forwarding lab exam reports, test results, and critical alerts in real time from its EHR to physicians’ smartphones. Waterbury estimates that with immediate notifications aligning better with physicians’ mobile workflows, the hospital has reduced patients’ average length of stay by nearly two days, saving $2,208 per patient.
Westchester Medical Center, a 1,700-bed health system headquartered in Valhalla, N.Y., has 10 hospitals spread over 6,200 square miles. By integrating facilities, providers, and transport across its enterprise through its clinical communication platform, Westchester reduced transport time between facilities by at least 11 minutes at 72 percent of its hospitals. One hospital experienced an average 34-minute time savings.
The integrated healthcare ecosystem established at Kennedy Health (now Jefferson Health), a three-hospital, 607-bed health system in southwest New Jersey, helped redirect ED “super-utilizer” patientsto more appropriate care settings. In 2013, Jefferson Health discovered that in one six-month period, just 21 patients accounted for 903 visits to its EDs, presenting with pain-related complaints and seeking opioids. This diversion protocol, which involved alerting ED staff through their clinical communication platform that patients from this group had checked in, reduced ED utilization among the targeted population by 73 percent. More important, Jefferson Health care managers were able to refer these patients to the opioid-abuse rehabilitation and behavioral health resources they needed.
Scratching the Surface
The results from these early adopters exemplify only a few of the efficiencies that are available through an integrated healthcare ecosystem. Eliminating wasted time, movement, and miscommunication has a far-reaching effect on reducing errors, ineffective or redundant care, and care delays, all of which pose costs for providers and patients. When physicians, nurses, and other care team members can improve how they work, their job satisfaction improves as well, resulting in less burnout and lower turnover.
With greater satisfaction come revenue opportunities, whether through higher bed utilization, lower readmission rates, greater Medicare payment for quality outcomes, or a general increase in patient throughput. This cumulative effect from uniting existing systems through mobile across a healthcare enterprise will differ for every organization, but all can expect financial performance, clinical outcomes, and experience measures to improve.
a. Orenstein, D. “Emergency Care Cost Estimates Are Too Low.” Brown University Press Release. April 29, 2013.
b. CRICO Strategies, Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report, 2015
c. “Is Texting in Violation of HIPAA?” HIPAA Journal, Accessed July 18, 2018.