We may be tempted to see 2018 as an exciting one for healthcare. Shifts in government regulation, innovations in drug delivery but increases in drug costs, Amazon’s (threatened) entrance into the market, chimeric babies, and many other events have commanded headlines but have not necessarily led to real improvement in the practice of medicine.
The current focus on sensationalism shouldn’t distract us from the less exciting but more troubling reality of the continued high cost and middling quality reflective of much of healthcare. And our lack of progress cannot be attributed to one single villain or one single cause — unfortunately, there are many of them, from the sublime to the banal. From Medicaid expansion or lack thereof, attacks on hospital staff, the opioid epidemic, medical school debt, the list can feel endless. Many of these challenges have given rise to provider burnout, amid the aforementioned climate of rising medical costs that ultimately trickle down to patients.
Despite these challenges, physicians, healthcare leaders, and stakeholders have an obligation to seize the moment, elevate the quality of medicine, and find new ways to overcome old obstacles. Here are some thoughts on six important opportunities that will come into focus in 2019.
Smarter, More Impactful Data-Driven Interventions
Precision therapy and immunotherapy are wonderful examples of next-generation medicine—the use of patient-specific information (and tissue!) to guide the most effective care. While 2019 is likely to be similar to 2018 for these advances, continued progress will still mean limited impact to healthcare delivery given the small scale of the interventions. Thus, I hope there is renewed focus on issues that affect an even broader swath of America.
Consider the current opioid crisis, which has contributed to a record-high number of drug-overdose deaths in the United States. Substance-use disorder, unlike cancer or heart disease, frustrates many physicians because they feel limited in their response. By empowering more physicians at the point of care with critical patient data, such as diagnosis or prescription history, or hospital-utilization patterns, we can positively influence patient care and outcomes. A patient-specific notification — for example, an alert that indicates a patient has a known herniated disc and has been to multiple hospitals seeking help, unsuccessfully — can support their care providers’ clinical decision making.
It’s important to note, this is not about punishing these patients —most of whom have real pain needs— by withholding care. Rather, it’s about supporting them in a more meaningful, lasting way (referring patients to a social worker or case manager, with access to a broader range of appropriate resources, or bridging them with medication-assisted therapy until they get to an outpatient clinic). This same patient-specific, data-driven construct can be equally impactful in hospital neonatal wards: having the right, real-time technology markers to flag newborns at risk for neonatal abstinence syndrome (NAS) allows care teams to create appropriate care plans and then follow these high-risk infants post hospital discharge.
Regulatory Overflow for Physicians
In 2018, beyond the ACA-related drama, we saw legislation pass such as the Chronic Care Act and the Opioid Crisis Response Act. Beyond (mostly) good intent, there’s actually some good stuff there, but unsurprisingly there’s also downside to the new legislation: more regulations, which almost inevitability leads to more paperwork for physicians, more time researching medical records, more time navigating their EHR.
As we learned in the early days of the EHR Incentive Program, all that extra documentation is correlated with high levels of physician burnout, which, in turn, is linked with myriad of issues, including medical errors. Fortunately, we’re seeing more and more tools and systems that can simplify the physician workflow, often by allowing them more efficient access to the data they need. Of note, while much of this data can come from outside the EHR, the data then has to be integrated into it, something that EHR vendors have not always made easy.
More Interoperability for Collaboration
Cross-health system and cross-provider collaboration is critical for good and cost-effective care, and interoperability is necessary for that collaboration. It’s meaningful (sorry) that in 2018, CMS overhauled (and renamed) its infamous “meaningful use” program in finalizing the “Promoting Interoperability” Rule.
This action reinforced the importance of secure data sharing between providers and 2019 will further clarify what that means, with final versions of the ONC’s Trusted Exchange Framework and Common Agreement (TEFCA) and related legislation, plus the growth of specifications such as SMART on FHIR. It’s important to note that interoperability itself is meaningless without the use cases it supports and can’t be an end goal; otherwise we’ll end up with tools that are interoperable but not actually useful (and show we didn’t learn anything from EHR design).
Growing Focus on Addressing Behavioral Health First
While behavioral health is core to the practice of all medicine, because of its complexities in management, additional regulation (exhibit A: 42 CFR Part 2), and lingering stigma, it often receives less attention. Yet behavioral health-related conditions undermine other disease management, like depression reducing medication adherence, and as a result have a significant effect on the quality and cost of care.
My medical practice in Seattle focused on HIV and high-risk care, and, while we have terrific medicines for the management of HIV, they are unsurprisingly ineffective when my patients don’t feel up to taking them. The data certainly support this. Fortunately, the move to value-based care has highlighted the cost associated with behavioral health and I think we will hear more and more in 2019 on the more obvious pain points.
The precipitous rise of ED psychiatric boarding, where patients are parked for days in the ED awaiting an elusive bed at a psychiatric hospital, is a classic example of this. The frenetic ED environment is terrible for these patients, their care in this setting is expensive to the system, and of course this type of patient/care mismatch is one of the contributors to provider burnout, as ED docs are frustrated that they can’t do more for the patient. Optimizing the care of these patients in the ED, with a faster and safer transition to a more appropriate care environment, will have a measurable cost and quality impact.
Pilot projects with substance-use disorder may provide a model; the ED Bridge initiative in California connects those identified in the ED as needing medication assisted therapy (MAT) with an outpatient clinic. It initiates the therapy at that moment in the ED, increasing the likelihood they will make it to the clinic appointment. Of course, there needs to be a relationship between the ED and the MAT clinic to ensure a successful transition, which speaks to the need for close collaboration and data sharing mentioned above.
Addressing Workplace Violence
We’re finally seeing workplace safety in hospital and healthcare settings getting a lot more attention by OSHA and other agencies. A recent survey of the 3,500+ doctors conducted for the American College of Emergency Physicians (ACEP) revealed that 47 percent of emergency physicians say they’ve been physically assaulted while at work, with 60 percent saying those assaults occurred in the past year.
When you look at other ED staff, like nurses, the numbers are even more stark—one survey saw 10 percent of nurses assaulted in just one seven-day period. While there has been real interest in practical solutions to decrease risk, like sharing information across hospitals about high-risk patients (of note, not to undermine their care, but to allow for proactive preventative measures to be put in place for both provider and patient safety), new regulations may force the issue. California, for instance, now mandates more robust workplace violence protocols and other states are expected to follow suit in 2019.
Social Determinants of Health
Similar to the case of behavioral health, 2018 saw an increased awareness and interest in the role of the social determinants of health in patient care. Food and shelter insecurity, for example, undermines healthcare delivery in both stark and insidious ways. How can discharging a homeless person to the street, for example, ever be a “safe” discharge?
Or, while governmental 340B funding ensures critical medications are available at reduced prices to various at-risk populations, there’s no place for them to safely store their medications if they have no housing, and no regular meal time to ensure the medications are taken with food.
A series of innovative approaches, some at the state level, are seeking to address this. The Accountable Communities of Health model in Washington state, and the Whole Person Care (WPC) project in California both include food and shelter insecurity as part of their focus; WPC actually mandated that housing be part of its grant proposals. The early WPC populations are small (often <100), but the approach — often led by a county behavioral health clinic, working with the local health system and health plan— may provide us with a model of care for the sickest (and most expensive) patients. To return to a consistent theme: For these members to successfully collaborate on these patients they need to share data and a common platform, another pitch for interoperability.
What else could 2019 bring?
Likely more value-based care, but how much and how quickly is still in question. Doing more to a patient will unfortunately still be better reimbursed than doing less. Sadly, amputating a leg due to complications from diabetes is markedly more lucrative than preventing ten people from getting diabetes in the first place. And more health systems will install Epic than not, but hopefully there will be more access to the patient data inside, for both their community caregivers and the patients themselves.
Ultimately as a doc and technologist I’m cautiously optimistic for 2019. There’s some indication that despite the sturm und drang, the ACA might be working, with many states’ plan premiums going down for next year’s enrollment. And the Office of the National Coordinator surprised everyone by announcing physician burnout would be a focus area for them in 2019, which at a minimum means greater attention to the impact any new regulation could have on medical practice. And perhaps most exciting, WiFi should finally get strong enough, and consistent enough, to rely on for patient care.
Scratch that last one. Let’s give WiFi a couple of years.
Photo: pagadesign, Getty Images