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.

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Innovation at the Point-of-Care: Rethinking the Doctor-Patient

Encounter

Oct 1, 2013

William Bria, MDPresident, AMDIS

Greg Shorr, MDCMIO, Rover Technologies

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

The Patient Experienceis always tied to theUser Experience

PX UXMeaningful Use

vs. Meaningful Provider-patient Interaction

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Patient vs. iPatientAbraham Verghese, MD


Rounds vs. iRounds


Work Habits of the 21st-Century InternBlock L et al. J Gen Intern Med 2013 Aug

Documentation = 40%

(Same as in 1989)

Direct Patient Care = 40%

(20% in 1989)

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Asynchronous Communication

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Clinical Implications of Empathyand Interpersonal Communication

•Improved Patient SatisfactionPhysician empathy and listening: associations with patient satisfaction and autonomyPollak, KI et al J Am Board Fam Med. 2011 Nov-Dec;24(6):665-72.

•Improved ComplianceThe Effects of Physician Empathy on Patient Satisfaction and ComplianceSung, SK et al Eval Health Prof September 2004 27: 237-251

•Improved OutcomesThe relationship between physician empathy and disease complicationsDel Canale, S et al. Acad Med 2012 Sep;87(9):1243-9.


“The VA’s Center for Innovation (VACI) identifies, tests, and evaluates innovativesolutions to help VA better serve Veterans. We develop programs that nurtureinnovation and create an environment where informed risk taking and progressivethinking are rewarded.”


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

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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


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”


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


The quality of the story is the single most important determinant of the quality of

clinical decision making.


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.

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This is a story!

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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


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?


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 on1. Interpersonal communication2. Observation3. Filling in scenario-specific knowledge gaps –not formal documentation


• 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”


– 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 Writingat the Point of Care


Standard pen

Digital pen

Stylus

Voice recorder


X XX

XX

XX

During sleep

X

X

W

W

W

WR R

RR D

D


Workstation Integration

X


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

Health & Medicine

confidential

rover technologies

rights reserved

physician

shoulder pain

patient satisfaction

patient experience

patients story