This is a timely topic as the Covid-19 pandemic enters a phase that I will categorize as the “Beginning of the End”. There are three EUA vaccines authorized for use in the US and a small handful more in other countries. Some countries have reached very impressive immunization rates that are representative of the beginning of achieving “herd immunity”. I would suggest this demonstrates that we are past the end of the beginning regarding the spread and horrific societal impacts of this widespread disease.
The CDC, ONC, HHS and the medical community are learning and sharing much as we get more and more data about the real-world efficacy of these amazing vaccines. When the race for a vaccine began, there were three approaches being pursued. Two were conventional and the third was based on messenger RNA (mRNA) which had never been approved by a national regulatory agency for use in humans. There is much to this fascinating story. Suffice it to say that unprecedented, new science has prevailed and its effect on future therapeutics will be real, significant, and long-lasting.
Perched at the Beginning of the End, it is time to carefully consider what we have learned from this pandemic experience and what we should do differently in the future. This is a deep and wide chasm, so I will focus on health IT (HIT) for this blog, since infrastructure, interoperability, informatics and systems integration supporting the process of reliably converting data into information, knowledge and ultimately wisdom and insight is my bailiwick.
Let’s look at what we have learned from Covid, or what the pandemic has taught us. Floating to the top, is that we can be agile and, going forward, we must be. Our workplace went from 80/20 onsite / Work from Home (WFH) to 20/80 in a matter of days and weeks. There is work yet to be done, but we clearly discovered that WFH does not encourage slackage or slackers. Rather, we have learned that it can be effective, efficient, and even preferred in some circumstances. WFH will continue as a core requirement and secure capability provided by HIT well into the future.
Rather than one or the other, HIT will employ a hybrid model that differs throughout the enterprise depending on numerous factors. Key is to be able to deploy and support wherever the enterprise goes. It is not a matter of supporting Work from Home everywhere, but WFH anywhere. The need for such flexibility and agility is a difficult and important lessoned learned from the past year.
Similarly, the amount of telemedicine employed was also turned upside-down. In that category, I include teleconsulting, telecare, teleradiology, teleDiagnostics and a plethora of care delivery encounters that are neither onsite, nor face-to-face. We experienced that it not only works well, but when properly integrated into the clinical workflow, it is a tool that was aspirational, but now commonplace. There are reimbursement and state licensure issues that need to be addressed, but no matter how that turns out, telemedicine will be utilized far more often than in the past. It will be appropriately integrated into care paths and care plans and become a tool that allows more care to be delivered, to more patients, more often.
From telemedicine, it is but a small technical step to consider Remote Patient Monitoring (RPM) and connected Patient Care Devices (PCD). These too must be seamlessly integrated into the workflows when implemented properly. The RPM/PCD must be tethered to the clinical care team in a reliable and flexible manner, including timely review, triage and clinically reliable communication and audit trails and automated escalation. This domain registered a significant uptick in utilization as patients were seen and cared for remotely.
As we reassigned resources to meet immediate imperatives, the care and feeding of infrastructure took a back seat. Consequentially, we learned that it can’t be ignored as we witnessed an increase in vulnerabilities, a staggering increase in serious data breaches, and found that the needs for additional productive capacity were not always easily met.
We witnessed the value of real-time genomics and the advancements of next generation sequencing (NGS) as individual Covid viruses were sequenced to track and respond to mutations and improve our understanding of the worst pandemic in 100 years. We should envision genomic data becoming a component of the electronic health record of the future, especially as personalized/precision medicine takes hold. These needs will dramatically increase the amount of storage required to support care delivery and thus the need for improved storage architecture and infrastructure.
Care coordination and communication were strained during Covid. Not only were the patients spread about, but so were the caregivers. We found the need to setup and breakdown care teams based on the clinical needs of the patient, but the mechanisms to create and manage these teams were wanting. Given the other lessons learned, it is clear to me that future care delivery models will place the patient at the center and require care paths, for a population, care plans for a patient, and care teams that support care coordination via clinically reliable communication.
Digital engagement with the patient (and guardians) expanded to keep the parties in synch and to identify and manage personal preferences. Some organizations expanded these capabilities based on a careful, well-crafted planning process. But for many, if not most who lacked the time or staff, it was based on happenstance.
One more lesson learned from all the Covid related research and protocol-based clinical trials, was that we experienced the beginning of research being linked to definitive care delivery, i.e., care paths and care plans.
Before moving to the nature of the future state, one more lesson learned should be examined – clinical burden and physician burnout worsened. While the release and implementation dates for ONC/CMS’ enabling Final Rules required to implement the requirements of the 21st Century Cures Act were delayed, the imminent, implementation deadlines for Interoperability, HL7 FHIR API use, and data-sharing provide a powerful pallet for providing improved clinical support to caregivers. These normalized and complete datasets will enable significant advancements in Clinical Decision Support (CDS), Artificial Intelligence (AI) / Machine Learning (ML), Analytics, and integrating Social Determinants of Health (SDOH) data. In combination with the new CMS billing reporting requirements, this will reduce the clinical documentation burden. Soon, because of the availability of these decision support technologies, clinicians will realize a direct and improved return on investment from their use of EHRs.
My next blog post will describe what we should do to support what we have learned. Fortunately, there are patterns that can be seen when analyzing these lessons learned. I’ve organized them into 5 categories to provide a playbook for implementation, including the unique and ever-changing demands for effective EHI security.