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The Art ofMedicine in adigital world

Table of contents 4 When redesigning healthcare, what really matters? By Amy Cueva, Chief Experience Officer and Paul Kahn, Experience Design Director Mad*Pow 7 From Rockwell to reality: the evolving role of the physician By William K. Kapp III, MD, MS, FAAOS CEO and Chairman, Landmark Hospitals and Technomad 10 A lost luxury: taking patients every step of the way By Steven M. Schiff, MD, FACC Medical Director, Cardiac Catheterization Laboratory CMIO, Orange Coast Memorial Medical Center 12 For physicians in the foxhole, fast and easy matters By Carl I. Schulman, MD, PhD, MSPH, FACS Director, William Lehman Injury Research Center Associate Professor of Clinical Surgery and Associate Director, Surgical Residency Training Program, University of Miami Miller School of Medicine 14 The collaborative system: transitioning to user-friendly healthcare By Jonathon Dreyer, Director of Cloud and Mobile Solutions Marketing Nuance Communications2 The Art of Medicine in a digital world

“ The best lesson I can give to the medical students and residents I teach is: listen to the patient if you want to figure out what the problem is. Today, we are frequently driven by technology crowding out the listening part. The science of medicine goes nowhere if you leave the human element out of the equation. Curing our patients starts with listening to them.” Myron Z. Falchuk, MD Chief, Clinical Gastroenterology Associate Professor of Clinical Medicine Beth Israel Deaconess Medical CenterThe Art of Medicine in a digital world 3

#artofmedicine When redesigning healthcare,what really matters? By Amy Cueva, Chief Experience Officer and Paul Kahn, Experience Design Director, Mad*Pow In order to redesign healthcare, we need to become new students “J ust when you of the problem—erase the assumptions we have and approach the think you know challenges with a fresh mind. We can achieve this by interacting and understand with the people who will be affected by the solutions we create the latest in and observing the situations we are trying to improve. technology, it sneaks up After all, it isn’t about the specific tools or technology, it is about and saturates crafting an ecosystem focused on care, one that delivers real and another part of meaningful value to people’s lives. Humans are hardwired to seek our world.” out meaningful connections. It falls to us to design technology that helps fortify relationships, shares information, and facilitates communication between individuals and their care teams. If we send ourselves back to design 101, we would learn that before we can create impactful solutions, we need to gain a full understanding of the end-users—their workflows, the obstacles and challenges they face, their frustrations, and their hopes. In healthcare, what really matters right now is connecting patients to the people, information, and resources they need. The path to better outcomes and decreased costs will be paved with reliable interoperability and patient-centered systems. Patients, healthcare providers and payers are all immersed in the same continuously connected mobile world—instant messages, email, applications recording, transmitting, and notifying. It is up to us to re-evaluate and harness the tremendous opportunities inherent within this technology and turn them into the most efficient and well-designed tools.4 The Art of Medicine in a digital world

Technology translates. “TechnologyIt turns typing, touching and speaking into digital information. should be theIt can interpret a stream of words into structured data that drives wind at ouractionable systems. And it can translate medical-pharmacological- backs, not ininsurance terminology into something patients can understand. our faces.”Technology connects.It sends data around the globe in seconds, immediately sharingimages, impressions, and sensations. It obliterates the distancebetween any two points on the network, moving information fromparent to child, laboratory to bedside, exam room to living room.Technology tracks.It records, stores and plays back. It calls up events, x-rays andprescription orders. It can tell you how many steps you tookand how fast you ran last week. It can tell you when to refill aprescription and congratulate you when you’ve achieved a goal.Technology should be the wind at our backs, not in our faces.We need to take these powerful capabilities and artfully createhealthcare technology that supports and empowers the way welive, not distracts from it.Innovations are plentiful, but cool tech alone will not solve ourproblems. We need to use human-centered design to improvethe experience of technology and drive toward better health.It is time to redesign healthcare technology into a highly reliablepoint of support for the person who can do the most to improve thepatient’s health: the patient.Healthcare solutions can be redesigned to empower the patientto become his or her own best care provider. Every patient is intouch with his or her thoughts, sensations and feelings every minuteof every day. We can’t continue to let their health information, planof care, and other valuable resources be locked up in a mazeof systems. We can design technology that provides themwith access to the right information in the right context at theright time, and effectively connect them with their own healthinformation and care team.The Art of Medicine in a digital world 5

“ Making documentation easier carte blanche would enable physicians to focus on taking care of patients. If you could talk to the patient and have voice recognition record what you and the patient are saying, and put that voice-generated data into discrete fields, then you basically would have an automated scribe. That would help physicians get work done quickly, accurately, legibly, and help them focus on patients.” Mary Veronica Daly, MD Chief Medical Information Officer Atlantic Health System6 The Art of Medicine in a digital world

#artofmedicineFrom Rockwell toreality: the evolving roleof the physicianBy William K. Kapp III, MD, MS, FAAOS, CEO and Chairmanof Landmark Hospitals and TechnomadIn Norman Rockwell’s, Doctor and Boy Looking at In order to get technology to truly work forThermometer, a white-haired man in a tailored gray physicians, it must drive productivity, be availablesuit sits on the edge of bed and is engaged atten- on-the-go, and act as an enabler between physiciantively with his patient. That physician made house and patient. For technology to do just that, therecalls and had the time to teach a young patient how needs to be a layer of intelligence that rests betweento take a temperature. But, that was then. the user and the system—something that mimics the ease of the paper chart and mirrors our workflowThe reality is that Rockwell’s physician actually spent while also leveraging the advantages of a digitizedmore time providing care than documenting it. He system that can capture, analyze and derive insight,wasn’t required to view patient data on a screen, and connect dots between seemingly incongruousdocument care on a keyboard in the hallway, or point- bits of information.and-click his way through a checklist of symptoms.In today’s digital era, getting physicians refocused on Moreover, while technology needs to keeppatients means finding ways to integrate technology physicians focused on patients, it also needs to dodirectly into current clinical workflows. so without sacrificing full utilization of the electronic health record (EHR) and related data capture. SuchIf it doesn’t work like physicians, technology must automate processes as appropriateit doesn’t work for physicians so that physicians can focus on high-priority effortsPhysicians speak a unique language. We observe and less so on data-entry duties. This will allowand assimilate a lot of seemingly unrelated data physicians to capture data in a way that makespoints about our patients to come up with a sense for us and the patients we serve, and alsodiagnosis. What works for us is intuitive technology. allows for the extraction of information for broaderWe need an electronic system that captures the population health management initiatives.unique conversational interaction between doctorand patient—not drop down menus that miss the My organization is working diligently to bring suchnuances of the patient’s unique story. Put simply, technology to life. We’ve assembled anour ability to capture the complete patient story in-house team to develop a cloud-based hospitalwhile remaining focused on the human life at hand EHR called ChartPad. Utilizing robust mobileis what the art of medicine is all about.The Art of Medicine in a digital world 7

EHR accessibility and voice-driven technologies, ChartPad takes into “Capturing account the needs of physicians while not losing sight of the critical the complete importance of patient engagement. patient story while remaining Simplicity and intelligence are disruptive for physicians focused on the and patients human life at Simple, intelligent technology isn’t just what clinicians want—patients hand is what the want that too. With the rise of the empowered patient, consumers are art of medicine demanding better access to technology and personal health data in is all about.” order to more effectively and efficiently manage their own care. As patients look to take charge of their own health and wellness, they will increasingly be in search of intuitive technology—like mobile apps and patient portals—that put the power of personal care into their own hands. As these disruptive consumer health technologies come to market, the focus needs to be on instilling simplicity in how patients interact and engage with technology to achieve improved outcomes. After all, if technology is not easy for patients to use, we can’t expect them to embrace this shift in personal health responsibility. For physicians and patients, truly disruptive technology must do three things—increase engagement, maximize the efficiency of care, and be available anytime, anywhere. It’s this type of intelligent technology that will allow us to once again embrace the Norman Rockwell vision of the doctor-patient relationship. In the end, Rockwell’s image is not only what patients expect, but also what we as physicians understand is the key to positive patient outcomes.8 The Art of Medicine in a digital world

“ A computer system is a tool, just like a scalpel is a tool. What if a surgeon’s scalpel changed every few weeks? How is it possible to deliver good care if the primary tool you’re using is changing on an irregular basis? It makes it hard for physicians and puts a barrier between them and their patients.” Ben Kanter, MD, FCCP Chief Medical Information Officer Palomar HealthThe Art of Medicine in a digital world 9

EHR A lost luxury: taking patients every step of the way By Steven M. Schiff, MD, FACC, Medical Director, Cardiac Catheterization Laboratory CMIO, Orange Coast Memorial Medical Center As far back as I can remember, there was never patient, and perhaps his or her family, I pull up the a time when I didn’t want to be a physician. It’s a health record on my laptop and we review our notes choice in which there is no equivocation: either you from the last visit. We discuss how treatments are want to be a doctor or you don’t. It encompasses working, complete templated fields together and, your life—there is no punching the clock, no walking using a section I have created called “Instructions away. Illness doesn’t take vacations, disease to the patient,” I outline action items and next steps. doesn’t go away for the holidays, and pain doesn’t I enlist their active participation in the creation of sleep. As physicians, we have accepted these truths this take-home document, and the content of as basic facts of our daily lives. these clinical notes exceeds the basic information required by Meaningful Use clinical care documents While I realize that technology can be unwieldy at (CCDs), which means I know my patients will leave times, especially for those of us who grew up before my office with a thorough understanding of their computers and the internet, I also see the incredible current health status. potential it holds for positively changing how we, as doctors, are able to provide care to our patients. This is a new era of patient-physician collaboration. We can leverage technology to enhance our part- Clinical information used to be the exclusive nership with our patients to create clinical notes province of the select few, and this knowledge that they can share with family members or use as a was then trickled down to patients; but I believe reminder of what they need to monitor and work on the electronic revolution in healthcare has allowed until our next visit. These take-away instructions are a shared and more collaborative relationship to an important piece of extending the continuum of develop. The more patients understand, the better care beyond the doctor’s office. their ability to participate in their own care, and the better their personal choices and decisions will be. I have been a physician for more than 35 years, In this pursuit, I have been using EHRs as a tool to and, to me, being able to escort my patients every help explain and work through health issues with step of the way—whether it is through an illness or my patients. simply to the front desk at my office—is a big part of what being a physician is about. Sitting side-by-side in the exam room with my10 The Art of Medicine in a digital world #artofmedicine

“ T here are 8,736 hours in a year, yet we expect a 60-minute annual wellness visit to keep our patients healthy for the remaining 8,735 hours of the year. That amount of white noise between visits doesn’t work. Healthcare needs to modernize. And who has been there to help us? The consumer electronic market. They connected our patients in the cloud and in the home and taught them how to use sensors (FitBit). We connect to them using telemedicine, patient portals and leverage these for team-based care, and they love it. This is the new model of care where the patient is at the center.” Andrew R. Watson, MD, MLitt, FACS CMIO and Medical Director Center for Connected Medicine University of Pittsburgh Medical CenterThe Art of Medicine in a digital world 11

#artofmedicine For physicians in the foxhole, fast and easy matters By Carl I. Schulman, MD, PhD, MSPH, FACS Director, William Lehman Injury Research Center, Associate Professor of Clinical Surgery and Associate Director, Surgical Residency Training Program, University of Miami Miller School of Medicine For physicians on the combat field, making patient care. And to be fair, it’s no easy feat to technology easy to use is nothing short of critical. balance those two critical needs in a single system, I am the director of the William Lehman Injury especially when you’re designing it for a highly regu- Research Center, where we developed MobileCare, lated and risk adverse industry like healthcare. a web-based software that integrates documentation, education and telemedicine. MobileCare was designed In the beginning… for Army physicians in the field. We are now applying Today’s technology does not mirror the manner by these lessons to the civilian healthcare sector. which physicians go about their day-to-day duties. My main concern is that current technologies force One of the most important things we had to take physicians to take a before and after approach to under consideration when creating MobileCare, patient care. Technology is an after-the-fact thought which was developed in partnership with the Depart- that physicians integrate post-visit, not at the point ment of Defense, was the actual design of the app of care. In essence, technology forces us to break- and the related user experience. The biggest lesson up our workflow into chunks that don’t fit seamlessly I’ve learned as a result of the experience is this: If a with each other. What’s lost in this approach is the certain technology or app is not something physicians opportunity to engage patients in the complete care like, actually want to use and feel like they can easily process—which includes the capture of their note in integrate into their workflow, they simply won’t use it. the EHR—and to also gather all of the patient’s infor- mation in real-time so it’s undeniably accurate and In my opinion, one of the main issues facing all phy- not subject to the degradation that happens when a sicians today is the fact that healthcare technology physician has to engage with the EHR, or even worse, was not designed with ease of use and physician has to leave the patient room and make the trek down workflow in mind. Put simply, user experience was the hall to document that care. not a high-priority consideration. Instead, many companies put their eggs in one basket aimed at One of the other major losses when it comes to the getting only half of the equation right when it came advent of technology in healthcare is that systems to health IT—and that was collecting data, not en- were only designed to capture data, not make sense abling doctors to provide high-quality, efficient of it. An original promise of the EHR was transparency,12 The Art of Medicine in a digital world

availability and accessibility of all information needed In the future…to inform real-time health decisions. And yet today The right EHR for physicians captures data withoutwe are merely storing much of this information. requiring extra physician time to do it, integrates dataUnfortunately, since it’s not organized or presented into a format that’s compliant, synthesizes data forin a way that facilitates a physician’s workflow, we coding and billing, and is so easy to use that everyonemust cobble together what we need from bits and involved in the patient care process—including thepieces of data scattered across multiple systems. patients themselves—could look, understand and interact with all of the information created.EHRs were designed to satisfy specific functionsfor distinct parts of the care process. Currently, The ideal EHR is also hands-free and sharesEHRs are all about making sure all the warnings information across various platforms and systems.are heeded and all boxes are checked. It’s not More so, it allows physicians to make smarterabout bringing the information together to make decisions faster, and enables them to spend morephysicians’ jobs easier so they can make faster, time with patients and less time on technology.more informed patient care decisions. Let’s consider a not too distant future. A physicianThe problem isn’t solely new regulations and enters an exam room, and the EHR immediatelyrequirements; it’s the fact that we’ve adopted systems begins recording the ensuing patient encounter.optimal for collecting data, not improving care. Everything the doctor and patient say is captured and collated as needed—unstructured notes for theAll of this leaves us spending more time care team and structured data to satisfy coding andinteracting with technology instead of focusing compliance requirements.on patients. As a result, our days are longer, ouradministrative duties are continually on the rise, and Based on the physician-patient conversation, theour patients are less satisfied. Still, I’m hopeful that system suggests a diagnosis, recommends andthrough innovation we can start to address some orders appropriate tests, and prints out and emailsof the patient engagement, physician workflow any post-visit instructions the patient might need.and data integration issues that have plagued thehealthcare industry over the last decade. Truly seamless and beyond intuitive, this is the vision for the smart patient encounter of the future.The Art of Medicine in a digital world 13

#artofmedicine The collaborative system: transitioning to user-friendly healthcare Jonathon Dreyer, Director of Cloud and Mobile Solutions Marketing, Nuance Communications People have come to expect and rely on the conveniences assistants to physicians and patients, fostering decision that technology brings to their everyday lives and this making and communication, not hindering it. Imagine doesn’t stop once they enter the healthcare system— being able to speak to your mobile device in real-time whether they are providers, patients or family members. and having a virtual assistant weed through vast amounts of information to determine an initial understanding of All of these players in the healthcare realm expect the what your recent barrage of headaches and nausea might same efficiencies and ease of use in their healthcare amount to prior to even visiting the doctor. experience as they do in their day-to-day lives. We are on the cusp of a revolution where technology is beginning Or, consider the benefits of not having to leave your home to mold itself around humans instead of forcing us to to access quality care from a doctor because you can conform to technology. speak to a personal avatar via your smartphone, tablet, TV or other connected device. A prime example? We no longer have to fumble with the television remote to find our favorite shows. Instead, we In a new world where patients are empowered and can simply speak to our TVs and request the show we’d physicians are tasked with balancing high patient volumes like to watch. and both the art and science of medicine each and every day, well-designed technology that’s intuitive is poised Today, although technology has begun to actually to be a game changer. These innovations can impact understand us, and the ease of conversational and not only the quality of care, but also lessen the financial intelligent interaction between people and electronics burdens of current inefficiencies in our healthcare system. has exploded, it has not yet fully made its way into our emerging, learning healthcare system. Why? Healthcare, The relationships we have with people are impacted one of the final frontiers when it comes to making the shift by the relationships we have with technology. One only from a paper-based communication system to one that needs to visit a doctor’s office and have him/her turn their is digital, has been slow to adopt emerging technologies. back to type information into the EHR to understand just Part of the reason for this is the complexity of the entire that. As the healthcare industry and the patients it serves healthcare system at hand, and the risk involved in such evolve over the coming years, technology must act as an change—people’s lives. enabler for clinicians who want desperately to spend more time with their patients. It must also help consumers more Still, the rise of intelligent, user-friendly systems in easily and actively participate in the care process as they healthcare is taking shape—and both physicians and will, in short order, be tasked with taking a more active role patients stand to benefit from this modernization. While in their own health and wellness. physicians have found adoption and use of health IT painstaking at times, this is changing. Usability and design A future where people talk and technology listens is at our have begun to take center stage—and the promise of fingertips. As systems gather intelligence and understand innovative intelligent systems that can provide clinical our intentions and individual nuances, they will rapidly decision support and cut through layers of complexity deliver the right information—at the right time, to the are emerging. Whether being integrated with EHRs, right place—unifying physicians, patients and the entire wearables, mHealth apps, virtual avatars or patient healthcare ecosystem, alike. portals, intelligent systems will, in time, act as reliable14 The Art of Medicine in a digital world

“ A core factor in the richness of a relationship is how good the raw communication itself is—one person speaking and the other person hearing. But another factor in a collaborative or participatory environment— which is what we’re striving for—is how well connected people feel in the dialogue, and this extends beyond just I speak and you hear…” “e-Patient Dave” deBronkart Patient Advocate and ActivistThe Art of Medicine in a digital world 15

#artofmedicineAbout the Art of MedicineThe relationship between physicians and patients is at the core of healing. This begins with hearing and understanding.Let’s reimagine healthcare—where physicians can get back to the art of medicine.Learn more at nuance.com/artofmedicineNuance is the market leader in creating clinical understanding solutions that drive smart, efficient decisions acrosshealthcare. More than 500,000 physicians and 10,000 healthcare facilities worldwide leverage Nuance’s award-winning,voice-enabled clinical documentation and analytics solutions to support the physician in any clinical workflow and on anydevice. For more information on Nuance healthcare solutions, visit nuance.com/for-healthcare Copyright © 2014 Nuance Communications, Inc. All rights reserved. Nuance, and the Nuance logo, are trademarks and/or registered trademarks, of Nuance Communications, Inc. or its affiliates in the United States and/or other countries. All other brand and product names are trademarks or registered trademarks of their respective companies.