One of the common complains of providers is “provider fatigue” over the many metrics and different reporting requirements in 2st Century Medicine.    SETMA experienced this after completing four patient-centered medical home and ambulatory accreditations (new for URAC and Joint Commission) and renewal of recognition for NCQA Tier 3 and accreditation for AAAHC between July, 2013 and June 2014, efforts to initiate Planetree accreditation failed because of “accreditation fatigue.”  SETMA providers were just not ready to face another complex and new set of standards.  Provider fatigue is real and must be recognized as metric fulfillment and reporting requirements are seen as “add on-s” to the excellent practice of medicine and to the maintaining of excellence in practice quality and safety.  The solution is continuing to make metric standards and reporting requirements easier to maintain.

The number of “things” which a provider is able to fulfill in a single visit and to maintain the fulfillment of long term depends upon three things:  how important is the task, how much time does it take to fulfill the task, and how much energy does it take to fulfill the task.  If the task is very important and if it takes little time and little energy, it is possible to fulfill many tasks without fatigue.  Automation and intuitive and simple clinical decision supports can avert fatigue and sustain excellence, while improving professional satisfaction.  An example of this can be reviewed at http://jameslhollymd.com/epm-tools/Automated-Team-Tutorial-for-the-EMR-Automated-Team-Function.  With proper design and deployment “an automated team” can solve these problems and improve care while avoiding provider fatigue.

One of the most complex and difficult tasks to perform by a provider is the fulfilling of State Health Department Disease Reporting requirements.  However, with a simple design, this complex requirement can be automatically fulfilled.  When a diagnosis is made and documented in the EMR, a template with all of the reporting requirements is note, an alert is sent to the care coordination department, and that department automatically makes a report to the state and sends a note to the provider that this task has been performed.  At SETMA, this very important, but complex, pubic health action requires zero time and zero energy of the provider, thus zero fatigue.

How can we change the future of healthcare?

Make it easier to do it right than not do it at all!  Imitate Henry Ford who automated the manufacturing of automobiles with assembly lines and in so doing made it possible for those who made cars to afford to drive them.  There are many aspects of patient care which can be automated.  Classically, SETMA has used clinical decision support (CDS)  as reminders to providers, but now we are realizing that many of the tasks which were the object of CDS, actually could and should be automated, requiring no input from the provider.

For instance, the value of the flu immunization is not enhanced by it being ordered by a healthcare provider, or by it being given by a registered nurse.  And, the process of a flu immunization can be automated. 

1. When a patient is given an appointment and the system determines that the patient has not had a current flu immunization and the appointment time is in the appropriate time frame to receive the vaccine, the system should order the flu immunization, and send the order to the nurse, to the chart and to charge posting. The provider is not involved which increases the probability that it will be done.
2. Additionally, the system should be programmed so that every patient who has not made an appointment in the time frame for a flu immunization should be notified electronically at the beginning of the flu-immunization season that they need to have a flu shot and toward the end of the immunization season, the system should check again to see who has not had the shot.

This principle can be expanded to all chronic conditions for which the patient is being treated and/or for all screening and preventive care the patient requires.  In the future, all healthcare process will be evaluated for: That which can and should be automated, all based on evidence-based medicine; That which requires human input based on patient-centered care,  This will give the healthcare provider more time to focus on the patient while fulfilling the processes (care) which we believe will improve the health (outcomes) and which will decrease the cost of excellent care.  Automation of care can help healthcare providers fulfill the “triple aim.”

Most routine and repetitive tasks in health care can be “automated“ which means that they can be ordered before the patient comes to the clinic.  In the design of The Automated Team functions, when the patient makes an appointment, the EMR automatically searches the patient’s record and creates orders for referrals, procedures and tests.  At the time of the visit, in The Automated Team functions, the following documents are also created:

1. A summary of the patient’s needed care for the nurse who will see the patient.
2. A summary of patient needs for improvement of care and for removing as much stress as possible from the provider, such as alerting the provider that the blood pressure, or the blood sugar, or the cholesterol, or other outcomes measures are not to goal.
3. A summary of tests, procedures or referrals which have been initiated for the patient.  This summary will explain what has been ordered, where and when the care will be competed and an explanation of why the care has been ordered and the benefit of the care to the patient.

These steps will improve the quality of care for the patient and the quality of life for the provider.  A great deal of stress will be taken off the provider who will have more time to spend with the patient giving attention to the patient’s interests rather than spending time fulfilling important but easily automated tasks.  It is possible that this process will reduce the work load of the healthcare provider by 30% or more.  If it does, it will be transformative to primary care by giving the provider the capacity to fulfill quality metrics while spending more time and attention on the patient.

The Vision

As we learn more about how to improve our health and as we are able to change the future of our health more, excellence in healthcare increasingly is dependent upon two things: a team approach and the automation of those standardized tasks, which while they are critical to excellent care, can be completed without requiring the time and attention of team members. This gives the team more time to interact with one another personally. This standardization and automation of care brings us one step closer to the ultimate promise of electronic patient management which is the ultimate goal of electronic patient records.  The Automated Team is the logical extension of clinical decision support.

The Team

The majority of healthcare is delivered and received in the ambulatory setting in a clinician’s office. While the healthcare team is much boarder, in the ambulatory setting, the principle members of the team are the patient, the nursing staff and the healthcare provider. Ultimately, while the standardization and automation of this team’s functions will spread across all areas of care, Southeast Texas Medical Associates’ efforts begin with diabetes. Each member of the team - patient, nurse, and provider -- contribute to the excellence of ambulatory care for diabetes.

The Plan

When a patient who has diabetes makes an appointment, based on evidenced-based medicine and national standards of care, the electronic record will immediately search the patient’s entire medical record to determine what tests, procedures, consultations or interventions are required and which have not been performed. Each of these interventions will be directed at the prevention of the complications of diabetes and/or at the improvement of the care of the patient with diabetes. Because diabetes is a progressive disease, excellence of care at one point in time may not reflect excellence of care at another time, thus the reason why the “automated team” needs an updated, current and complete plan of care and treatment plan at each visit.

The Automation

When the patient presents for their appointment, three documents will have been prepared:

1. For the nurse, a document will have been prepared which lets the nurse know what elements of his/her contribution to the team’s effort are not up to date and need to be addressed, such as The LESS Initiative, the 10-gram monofilament sensory examination, immunizations, medication reconciliation, etc.
2. For the patient, a patient engagement and activation document will have been prepared which tells the patient what tests, procedures or referrals have been scheduled. An explanation will be provided to the patient as to why he/she is being asked to have these tests, procedures, or appointments. As stated above, all interventions will be directed toward the improvement of the patient’s care and the avoidance of the complications of diabetes. With this document, the patient will know what his/her responsibility is to support the efforts of the team.
3. For the provider, a document will have been prepared which explains the information which has been given to the nurse and the patient. The provider will be alerted to whether or not the patient has been treated to goal for diabetes and if they are not, the provider will be encouraged to change medication, life-styles, education, etc., in order to achieve control.

The Team’s Activation - True Patient-Centered Care

Each team member will have access to the documents given to other members of the team. Each team member will know what is expected of the team and each team member will know the goals are for the entire team. Because the team will be spending less time on the tasks of ordering and scheduling tests, procedures and referrals, there will be more time for the building of relationships and for the engagement and activation of each member of the team