An Interview With Dr. David Custodio Pt.2: Healthcare Digitalization

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In part one of my interview with healthcare thought leader Dr. Custodio we covered the current challenges facing U.S. healthcare.

In part two of the interview we discuss healthcare digitalization, the unexpected complexities of implementing new systems, as well as the necessities healthcare providers must consider when aiming to provide better care for patients.

“How do healthcare systems balance competing priorities such as creating revenue and profit while providing positive clinical outcomes?”

On initial inspection, it really seems like it’s competing priorities of getting these revenues in while providing high quality and high experiential care. But the reality is they’re not competing priorities.

What you find is that high-quality care which results in the highest clinical outcomes is really the most efficient and cost-effective care.

What we always preached was if you do the right thing, and eliminate the unnecessary variation in healthcare, you’ll get the outcomes that you want, and that happens to be the best way to do that at the lowest cost of care.

So what we all strive for, what we all should try for is evidence-based care with, following those best recommendations, and then you’ll get those outcomes which also then result in better revenues. 

If you do have high-value care then you’re efficient and no matter what your payment model is whether it’s fee-for-service or value-based, you’re going to get those returns, and what you also find is providing that higher-quality care results in a better patient experience. 

Better outcomes obviously result in happier patients and happier families. 

I met some physicians (Stephen Trzeciak and Anthony Mazzarelli) who have a book called Compassionomics and they have found that being compassionate in your care and being caring in your provision of care actually makes a difference. 

You have better outcomes with patients, you avoid missed opportunities for care that result in adverse out care and it improves burnout in your providers. It also has benefits for patients, across a variety of conditions, and these authors purport that being compassionate in your care actually results in better economics.

Better care. Better outcomes. Better caring. All result in better clinical outcomes with our patients and better financial outcomes for our institutions.

“Does the constant evolution of technology and platforms put healthcare systems off making changes?”

I think it is a challenge. During my experience with the last healthcare system, we invested heavily in electronic health records and had done so on several occasions. This was our third iteration but it went from a $20 million project to a $50 million project that we realized was underfunded. 

If you look at the cost of health information management technology, it is starting to grow exponentially, and you couple that with the workforce shortages that we talked about, that’s a challenge. 

I don’t think it’s going to stop people from wanting to get there. I think the idea is we’re just gonna have to modify it along the way. Whereas you thought if you’re gonna put in a certain program we can plan, implement, measure, and see how we’re doing. 

In this case, because it’s such a long process, I think you have to ask, “What are the interim goals?” and “What are the interim metrics that we can utilize?”, while we may not have an exact ROI but we can look at certain areas and then scale. 

What my healthcare system did was look at what we are implementing, and what we can see and measure and change. And then whether it’s a process change or a true outcome change, we can measure and then perhaps extrapolate.

There are certain IT setups and systems where you can measure the ROI. There are other ones where you’re just gonna have to take some leaps of faith that you’re doing the right thing. But what can we do in the interim with those smaller milestones? — Those KPIs along the way aren’t as simple as “We had an 18% return over three years that paid off our break-even point” It’s just not that simple, however, the need for it isn’t going away.

What healthcare systems are going to need to do is find a way to continue that journey and continue to do the right thing along the way. It’s not gonna be a one-and-done. You’re gonna have to have executive leadership and sponsorship and then you’ve got to have good change management skills to work through that.

It’s a challenge but I think if you look at healthcare in general whether it’s the digital transformation, whether it’s the payment changes, whether it’s the workforce labor, there’s always something that’s going to be in your way. 

You know that you’re gonna need to overcome that mountain there in front of you. We can climb it and we’ll get to the top of it. But on the other side, There’s another mountain. So what you’re gonna need to do is take those lessons learned and things that you did.

“How did you manage to understand the success of the electronic health records project?”

We went from paper to electronic when I was in that system. Then we went from one electronic to another electronic that was hosted by a different system and then we cut the umbilical cord and went to a fully wholly owned instance of it. And so along the way, there were different areas where we could see improvements.

We did along the way set up what those interim goals were. ‘What could we do?’, ‘What was our turnaround time?’ ‘What were those measurable things that we could actually see by integrating?’. The typical stuff, days in accounts receivable, all those things because we had separate financial accounting systems from our electronic health record. 

Then we went to a fully integrated solution where our billing, and accounts receivable were all on that same system we could track everything. The goals that we set up are to say, “if we do this right” we should see a decrease in days accounts receivable, and we should see an increase in our collection. 

We knew that if we integrated the systems appropriately then we’d be able to monitor the things that really matter to us in order to achieve successful outcomes. A few examples would be:

  • time to first appointment compliance.
  • the effectiveness of our surgeries and specialties.
  • comparing our own outcomes with other facilities.
  • to identify if we’re losing cash where we shouldn’t be, and the reasons for it.

“How important is IT interoperability when it comes to decision-making?”

Epic iteration #1 – Integrating healthcare records

I think it’s extremely important. With iteration one we had a functioning electronic health record, and it worked very well in the hospital setting. We had separate electronic healthcare record systems in the provider group, and in the surrounding areas, so ideally we’d want to build something in between that consolidates and allows them to work well together.

This sounded great on paper, but it really didn’t come through.

The healthcare system made the decision to go to our providers and our institutions on an integrated healthcare record. And that’s what iteration two was, but we did it through a minority owner who had multiple hospitals and we went in on their system. 

Epic iteration #2 – Sharing data between healthcare providers

Iteration two was definitely an improvement as we had providers and hospitals on the same record. So I as an emergency physician could see the notes from previous appointments for “Mrs. Jones”.

Via the new IT system, I can see her appointment last week with her doctor and “these are the three things that he or she did”, and I could utilize that information so I don’t order the same test that was just done either here or at an outpatient facility.

Epic iteration #3 – Unifying data silos

The last iteration of the switch was to bring all data sources together because our financial platforms were on one and the accounting solution was on another so it’s extremely important to have that integration. 

That’s why this particular institution made a $50 million investment in moving to that next instance of that integrated level because the strategy group felt that, “yes, it’s a heavy initial investment, but ultimately, the ability to know what’s going on at any point in time in one dashboard could be invaluable.” And it was, for example understanding what appointments are looking like in the outpatient setting, and having that information in a usable format was key. 

So long story short, it’s extremely important to have that integration, the ability to understand what’s going on across the entire spectrum, versus little silos or departments is key.

“If it’s easier to join the dots across different healthcare systems does that make decision-making easier for everyone?”

Yes, as we introduced each instance of Epic more healthcare systems and departments were able to see the great benefits of unifying silos and data sharing. Although I still have some nightmares about the challenges we faced during my time as a chair of the department.

Financial departments

Where the challenges once were for our finance teams, who had individual software programs in their registration teams, were de novo into this electronic health record. However, this required a lot of change management, and pre-work to show the importance of implementing Epic, compared to what you’ve done for the last 20-plus years.

Despite this, having both software programs in one place allowed providers to become more efficient resulting in:

Streamlined financial operations increasing efficiency, reducing manual errors, and accelerating revenue cycles.

Improved financial visibility with real-time financial data producing more effective financial analysis, budgeting, and decision-making.

Enhanced cost control and financial planning for better financial visibility when monitoring expenses, vendor payments, and budget utilization.

Medical & emergency departments

In an effort to save time, we did patient registration on different platforms than the one nurses and doctors were using, which dissatisfied the personnel but extremely dissatisfied the patient. 

Not having seamless access to relevant information led patients to question “Why are you asking me all those same questions that I just answered 37 seconds ago” creating frustrating experiences for patients.

Our goal here was to change this so caregivers don’t have to say, “Are you allergic to this? What medications are you taking? Etc” resulting in:

Continuity of care by allowing healthcare professionals to access patients’ comprehensive medical histories, including diagnoses, medications, allergies, and treatment plans.

Improved patient safety and enhanced care coordination providing staff with access to up-to-date information, and helping staff avoid potential medication errors or harmful interactions. This coordination minimized the duplication of tests, procedures, and treatments, streamlining care delivery.

Inclusive patient engagement with secure access to their own health information, patients could review test results, and participate in shared decision-making. This promoted transparency and empowered patients to actively manage their own health.

Informed decision-making for caregivers by quickly reviewing medical histories, tracking population trends, and identifying patterns in patients’ health conditions aiding in more accurate diagnoses, personalized treatment plans, and proactive preventive care.

Time and cost-saving by eliminating the need for manual record retrieval or the duplication of tests and procedures, streamlining workflows, and reducing administrative burden drove operational efficiency.

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