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Bringing Zen To Healthcare:  Transformation Through The N of 1

Posted on July 21, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The following essay wasn’t easy to understand. I had trouble taking it in at first. But the beauty of these ideas began to shine through for me when I took time to absorb them. Maybe you will struggle with them a bit yourself.

In his essay, the author argues that if providers focus on “N of 1” it could change healthcare permanently. I think he might be right, or at least makes a good case.  It’s a complex argument but worth following to the end. Trust me, the journey is worth taking.

The mysterious @CancerGeek

Before I share his ideas, I’ll start with an introduction to @CancerGeek, the essay’s author. Other than providing a photo as part of his Twitter home page, he’s chosen to be invisible. Despite doing a bunch of skillful GoogleFu, I couldn’t track him down.

@CancerGeek posted a cloud of interests on the Twitter page, including a reference to being global product manager PET-CT; says he develops hospital and cancer centers in the US and China; and describes himself as an associate editor with DesignPatient-MD.

In the essay, he says that he did clinical rotations from 1998 to 1999 while at the University of Wisconsin-Madison Carbone Comprehensive Cancer Center, working with Dr. Minesh Mehta.

He wears a bow tie.

And that’s all I’ve got. He could be anybody or nobody. All we have is his voice. John assures me he’s a real person that works at a company that everyone knows. He’s just chosen to remain relatively anonymous in his social profiles to separate his social profiles from his day job.

The N of 1 concept

Though we don’t know who @CancerGeek is, or why he is hiding, his ideas matter. Let’s take a closer look at the mysterious author’s N of 1, and decide for ourselves what it means. (To play along, you might want to search Twitter for the #Nof1 hashtag.)

To set the stage, @CancerGeek describes a conversation with Dr. Mehta, a radiation oncologist who served as chair of the department where @CancerGeek got his training. During this encounter, he had an insight which helped to make him who he would be — perhaps a moment of satori.

As the story goes, someone called Dr. Mehta to help set up a patient in radiation oncology, needing help but worried about disturbing the important doctor.

Apparently, when Dr. Mehta arrived, he calmly helped the patient, cheerfully introducing himself to their family and addressing all of their questions despite the fact that others were waiting.

When Dr. Mehta asked @CancerGeek why everyone around him was tense, our author told him that they were worried because patients were waiting, they were behind schedule and they knew that he was busy. In response, Dr. Mehta shared the following words:

No matter what else is going on, the world stops once you enter a room and are face to face with a patient and their family. You can only care for one patient at a time. That patient, in that room, at that moment is the only patient that matters. That is the secret to healthcare.

Apparently, this advice changed @CancerGeek on the spot. From that moment on, he would work to focus exclusively on the patient and tune out all distractions.

His ideas crystallized further when he read an article in the New England Journal of Medicine that gave a name to his approach to medicine. The article introduced him to the concept of N of 1.  All of the pieces began to began to fit together.

The NEJM article was singing his song. It said that no matter what physicians do, nothing else counts when they’re with the patient. Without the patient, it said, little else matters.

Yes, the author conceded, big projects and big processes matter still matter. Creating care models, developing clinical pathways and clinical service lines, building cancer centers, running hospitals, and offering outpatient imaging, radiology and pathology services are still worthwhile. But to practice well, the author said, dedicate yourself to caring for patients at the N of 1. Our author’s fate was sealed.

Why is N of 1 important to healthcare?

Having told his story, @CancerGeek shifts to the present. He begins by noting that at present, the healthcare industry is focused on delivering care at the “we” level. He describes this concept this way:

“The “We” level means that when you go to see a physician today, that the medical care they recommend to you is based on people similar to you…care based on research of populations on the 100,000+ (foot) level.”

But this approach is going to be scrapped over the next 8 to 10 years, @CancerGeek argues. (Actually, he predicts that the process will take exactly eight years.)

Over time, he sees care moving gradually from the managing groups to delivering personalized care through one-to-one interactions. He believes the process will proceed as follows:

  • First, sciences like genomics, proteomics, radionomics, functional imaging and immunotherapies will push the industry into delivering care at a 10,000-foot population level.
  • Next, as ecosystems are built out that support seamless sharing of digital footprints, care will move down to the 1,000-foot level.
  • Eventually, the system will alight at patient level. On that day, the transition will be complete. Healthcare will no longer be driven by hospitals, healthcare systems or insurance companies. Its sole focus will be on people and communities — and what the patient will become over time.

When this era arrives, doctors will know patients far more deeply, he says.

He predicts that by leveraging all of the data available in the digital world, physicians will know the truth of their experiences, including the food they eat, the air they breathe, how much sleep they get, where they work, how they commute to and from work and whether they care for a family member or friend, doctors will finally be able to offer truly personalized care. They’ll focus on the N of 1, the single patient they’re encountering at that moment.

The death of what we know

But we’re still left with questions about the heart of this idea. What, truly, is the N of 1? Perhaps it is the sound of one hand clapping. Or maybe it springs from an often-cited Zen proverb: “When walking, walk. When eating, eat.” Do what you’re doing right now – focus and stay in the present moment. This is treating patients at the N of 1 level, it seems to me.

Like Zen, the N of 1 concept may sound mystical, but it’s entirely practical. As he points out, patients truly want to be treated at the N of 1 – they don’t care about the paint on the walls or Press Ganey scores, they care about being treated as individuals. And providers need to make this happen.

But to meet this challenge, healthcare as we know it must die, he says. I’ll leave you with his conclusion:

“Within the next eight years, healthcare as we know it will end. The new healthcare will begin. Healthcare delivered at the N of 1.”  And those who seek will find.

EMR Impact on Patient Care Differs, But Doctors Never Win

Posted on July 14, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Nearly all physicians agree that using EMRs isn’t great for their relationship with patients. But, hospital-based and office-based physicians seem to have different reactions to the problem. (Neither group is happy with their lot, but I’m sure you already guessed that much.)

The study, by researchers at Brown University and Healthcentric Advisors, is based on the open-ended answers provided by 744 doctors to a survey question: “How does using an EHR affect her interaction with patients?” (The question was posed by the Rhode Island Department of Health in 2014.)

In analyzing the responses, researchers found that office-based physicians and hospital-based physicians had different concerns about patients care and EMR use.

Office-based physicians, who typically bring their computer into the exam room, worry that staring at a computer screen will undermine the quality of their visit with the patient. “[It’s] like having someone at the dinner table texting rather than paying attention,” one doctor wrote.

Hospital-based physicians, for their part, usually do their record-keeping on EMRs based outside the exam room.  They said that record-keeping took up too much time, leaving little for direct contact with patients. Said one physician: “I now spend much less time [with] patients because I know I have hours of data entry to complete.”

To maintain their standards of patient care, physicians are doing the data entry at home rather than at work, sometimes many hours at a time. Others are taking CME classes which promise to help them integrate EMR use with patient consults in the least disruptive manner. But nobody had found any good solutions to the patient care conundrum.

Of course, we knew most of this already. This study just offers some added color to a picture we’ve already seen. Both patients and physicians are suffering under current models of EMR use, and there’s little relief on the horizon.

Yes, a few physicians said that EMRs hadn’t impacted their time with patients. This might’ve been encouraging, but this group included one physician who treated newborns and another using a scribe to handle data entry during consults.

And there were a few respondents that cited positive aspects of EMR use in patient care. For example, one hospital-based doctor noted that EMRs offered him an easy way to look at a comprehensive patient history. Some office-based physicians noted that web-based patient portals were improving their patient interactions.

But the striking thing here is that few if any physicians suggested that EMRs offered any ongoing clinical benefits. As researchers have discovered many times over, most doctors saw their EMR use as a work requirement rather than a clinical exercise. This only underscores that as they presently work, EMRs benefit administrators, not care providers.

I wish I was so smart that I’d come up with some sort of solution to this problem. I haven’t. But it doesn’t hurt to harp on the existence of the problem. We should remind ourselves over and over again that it’s time to roll out EMRs that support clinicians.

When Patients Know More Than Doctors

Posted on May 14, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

With a title like that, I know I’m bound to get a visceral response from some doctors, but hear me out. As someone told me today, the thing I love about John is that you know he’s going to tell you what he really thinks. He’s not going to hold back. Hopefully that’s true. Plus, I certainly welcome other people to provide opposing viewpoints so that we can all learn together.

First I should make it clear that I’m a great patient. I have extreme respect for the doctors I work with and follow their care plans to a T. For example, as a child I took accutane. That requires you to take pills twice a day. I think there may have been 1 or 2 times I missed taking my pills in 6 months. That’s pretty good if I say so myself. Regardless, I’m quite good at following the doctors care plan for me. Over time I have developed what I call a trust but verify approach. I trust that the doctor is doing what’s best, but I do like to confirm my understanding of why it’s being done when its a complicated situation. I don’t do this for things like common coughs and colds.

With this in mind, I was kind of blown away recently when someone told me about their 20 year old son who’s a diabetic. This patient and his parents had been dealing with his disease for about 15 years. As part of dealing with the disease they’d studied it and the various treatment and management options in depth. As he said, “we set a Google Alert and have read every study and discussion about the topic for 15 years.”

After moving, this diabetic patient went to see a new doctor who had just gotten out of medical school. A short discussion started and the patient quickly realized that he knew a lot more about his condition than his new doctor. What a challenging situation this must be for the new doctor.

I think most doctors are ok with this situation and have been dealing with chronic patients that know a lot about their disease for a long time. However, the availability of medical information is helping a lot of patients to be very well informed on their health issues. I wonder if a doctor use to treating well informed chronic patients has lessons we can apply to well informed general patients.

No doubt we’re in the stage of learning a new dance with a new partner. I’m not suggesting that we should change who’s leading the dance. The doctor should still be the lead for a lot of reasons. However, I am saying that the leader shouldn’t be surprised when their dance partner wants to provide some feedback on the choreography they’re doing. The leader might just find that working together they can produce even better results.

Side Note: It seems appropriate that I should use a dance analogy with the So You Think You Can Dance premiere tonight.

How Can I Spend Less Time in a Patient Encounter?

Posted on March 27, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I was reading on LinkedIn the other day, and someone suggested that in far too many ways we’re restricting our view to the following question:

How can I spend less time in a patient encounter?

While this certainly applies to our use of technology in healthcare it goes well beyond just EHR. Although, one challenge with technology like EHR is you get exactly out of it what you design it to do. If the focus of your EHR is just about minimizing the patient encounter, then that’s what you’ll get. If the focus of your EHR is to maximize reimbursement, then that’s what you’ll get. If the focus of your EHR is to meet government requirements, that’s what you’ll get.

Instead, of you focus an EHR on providing amazing patient care, that’s what you’ll get.

Many like to blame the EHR vendors for not producing EHR software that improves patient care. While I think they hold some responsibility, they are mostly just trying to satisfy the demand of their customers.

Healthcare deserves better and we need to find ways to incentivize doctors to want an EHR because it improves patient care. Otherwise, we’ll keep getting great billing engines which minimize the patient encounter at the expense of great health care.

Does an EMR Improve Patient Care?

Posted on September 16, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Everyone probably realizes by now that I love to read first hand experiences with EMR and EHR. I guess I’ve always loved stories and I’ve always loved to tell stories, so maybe that’s where that comes from. I guess this is why I loved Katherine Rourke’s post called “Would An EMR Have Improved My Son’s ED Care?” on the Hospital EMR and EHR website. It’s a great read if you love first hand experiences with EMR as I do.

Katherine does raise a challenging question, “Does an EMR improve patient care?”

In past presentations, I’ve always put the idea of an EMR improving patient care under the “possible EHR benefits.” (See a full list of EMR and EHR Benefits) As many things in life there’s a big “Depends!” that is the b est answer to that question. The answer to this question depends on what kind of care you were offering previously, the type of care you offer, the EMR you chose, the features you chose to employ in that EMR, the match between your workflow and the EMR workflow, and I’m sure another dozen other depends as well.

What’s more important to point out is that an EMR can improve patient care. I certainly can’t guarantee that an EMR will improve patient care in your clinic, but I’ve seen many cases where it has improved patient care and so I know it’s possible. The biggest determining factor in whether an EMR will improve patient care in your clinic is your desire to have it do so.

Many times in life, you get what you want. Do you want an EMR to improve your patient care? Or were you too focused on wanting to get the EHR Incentive money? Not that these and other benefits are mutually exclusive, but the focus of your EHR implementation matters a lot. Make sure you’re focused on the right things and your EMR selection and implementation will go 100 times better. In fact, it will even improve patient care if you want it to.

12 Reasons Why EMRs Improve Patient Care

Posted on March 28, 2011 I Written By

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she’s served as editor in chief of several healthcare B2B sites.

While HIT insiders and pundits take it as a given that installing an EMR benefits everyone, it’s not so obvious to some gun-shy practices.   Even researchers like myself switch gears every time I try to explain what EMR technology can do.

That’s why I was pleased to come across the following blog item. This piece offers a very solid list of twelve reasons why EMRs can improve patient care, including the following (in no particular order of importance):

*  EMRs are less subject to physical damage and data loss than paper records, as the data can be backed up and stored elsewhere.

* EMRs reduce wait times for patients, as there’s no need to wait for a receptionist to pull a chart and get it to the treating clinician.

* Data stored in an EMR can be sent more easily to other clinicians than when using a paper record. (This may not be true if the EMR is balky — in reality, only an HIE can really fulfill this promise — but it should be true.)

* EMRs that integrate e-prescribing reduce the risk that a  patient will get the wrong drug/dose, as poorly-written prescriptions stop being an issue.

The piece also notes that with an EMR in place, practices should have neater workspaces to use (no paper accumulation) and have better access to care documentation during emergencies.

Now, to inject a note of skepticism here, it’s unlikely that most practices will realize all of these benefits quickly.

In particular, I highly doubt that practices will be able to cut back on paper quickly, since if nothing else, they’ll have to do something with the reams of letters and faxes that other providers send to them, and possibly images as well. (It’s no coincidence that the author works for an HIT consulting firm.)

Still, it’s good to see a well-rounded wrap-up of how EMRs might support day-to-day patient care.  It’s easy to assume that everyone understands EMRs’ potential — but I’d argue that many clinicians are just beginning to draw these conclusions.

That being said, would you add any clinical care benefits to our blogger’s list? Would you disagree with any of his conclusions?

Balancing Privacy and Security with Patient Care

Posted on December 23, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Healthcare InformationWeek has an article that discusses the challenges of EMR security and privacy. A lot of the stuff is nothing new to those of us in the healthcare space. Although, it’s interesting to see how they summarize things like the goal to be full EMR by 2014 and the EMR stimulus money.

However, the article did include these interesting stats on the number of breaches that happen in healthcare and the focus IT managers put on privacy and data security in healthcare.

Healthcare providers and other health businesses aren’t stepping up to protect privacy, according to a recent study. Some 80% of healthcare organizations have experienced at least one incident of lost or stolen health information in the past year, according to the study, released this month from security management company LogLogic and the Ponemon Institute, which conducts privacy and information management research.

Also, some 70% of IT managers surveyed said senior management doesn’t view privacy and data security as a priority, and 53% say their organizations don’t take appropriate steps to protect patient privacy. Less than half judge their existing security measures as “effective or very effective.”

I was surprised that 80% of organizations have had an incident of lost or stolen health information. However, I honestly don’t see this ever changing. Stuff happens even with the very best efforts.

I did also like this quote of John Halamka about the challenge of balancing privacy and security with sharing the patient information to provide better patient care.

“You want to protect the patient’s preferences for confidentiality,” Halamka said. But you also need to get information where it’s needed. “If you come to the emergency department in a coma, and you have a record that includes psychiatric treatment, HIV, drug abuse, and other information, would you share part of it or all of it? My preference would be all of it, with the hope that emergency workers would use it discreetly, to save my life.” But other people may feel differently, Halamka said, and healthcare policy needs to serve all those needs.

I’m a little surprised that Halamka has had psychiatric treatment, HIV and drug abuse. He’s doing quite well considering that history. (that’s sarcasm in case you didn’t note it) His history aside, I’m totally with him on wanting that information available as well. However, he’s totally correct that many people wouldn’t want that stuff shared. Enabling the consumer to make that decision though is a hard nut to crack.