Revamping the delivery of women’s health care to meet future demands will require a number of changes. In the first 2 articles of this series, we introduced the reasons for change, suggested the use of the ‘Triple Aim’ concept to (1) improve the health of a population, (2) enhance the patient experience, and (3) control costs as a guide post for changes, and reviewed the transformational forces of payment and care system reform. In the final article, we discuss the valuable use of information technology and disruptive clinical technologies. The new health care system will require a digital transformation so that there can be increased communication, availability of information, and ongoing assessment of clinical care. This will allow for more cost-effective and individualized treatments as data are securely shared between patients and providers. Scientific advances that radically change clinical practice are coming at an accelerated pace as the underlying technologies of genetics, robotics, artificial intelligence, and molecular biology are translated into tools for diagnosis and treatment. Thriving in the new system not only will require time-honored traits such as leadership and compassion but also will require the obstetrician/gynecologist to become comfortable with technology, care redesign, and quality improvement.
The Problem
Payment reform and care redesign only partially lead to an improved health care system, but other carefully chosen changes are needed to meet the challenges ahead.
Force 3: digital clinical data and health information technology
By 2020, the transformation of clinical data into electronic records likely will be nearly complete. A robust functioning electronic medical record system with capabilities for documentation, result retrieval, ordering, and decision support and interoperability (ability of systems to exchange information) with outside systems will be in most physician offices, clinics, and hospitals. Currently, most practitioners are in their learning curve with electronic records; however, adoption of electronic records continues, with most providers now showing favorable usage. That said, challenges still exist, particularly for those older practitioners and those in solo practices. Those physician practices and organizations without these robust information technology solutions will be disadvantaged and unable to function as part of an effective clinical team. Furthermore, patients increasingly see electronic records as a benefit to their care. We believe that increased regulatory control, market forces, and industry consolidation should solve the current problem of poor interoperability. The Office of the National Coordinator program of meaningful use incentivizes organizations to adopt standards for information exchange and, although still somewhat limited and with multiple barriers, is an example of regulatory pressures to adopt interoperability. Today’s hodgepodge of information storage is akin to other past digital battles, such as video recording formats that were resolved by market forces. It will also be necessary to solve problems that are related to semantic interoperability, security issues, and data definition issues. The records will include multiple formats of images, sounds, videos, and waveforms all at immediate retrieval. The patient’s ‘record’ will be a collection of information obtained locally and from other sources of care.
In this world of exchangeable patient information, the patient becomes the “owner” of the information. Health care providers and institutions become custodians of the information generated by their care. Thus, the information is freely available to all providers that are given permission by the patient (or their designee). In addition, widespread use of patient portals allows the patient to contribute and constantly check the information recorded by providers. As an important part of the care team, the patient quickly can check their history, allergies, medications, transfer clinical data, answer health questionnaires or surveys, and help guide their care. Patients will be connected constantly to their health care team by smartphones and other mobile communication devices. Home monitoring devices will allow care and assessment to occur 24/7/365, because internet-connected devices continually transmit data to data centers. In these centers, computer algorithms that are based on evidence-based protocols screen data, obviate the need for the addition of expensive human staffing, and immediately alert providers of concerning values and trends. As a result of these electronic connections, patients will have the opportunity to arrive routinely with completed paperwork to scheduled surgeries or office visits and with large amounts of collected measurements for consultations; therefore, evaluations would take place with more complete background information and data sets. Office visits will be more efficient and effective and result in a reduced number of physical office visits and potentially a reduced provider workload.
Furthermore, once information and communication becomes digital, the opportunities for care to be provided by telemedicine from remote sites should expand rapidly. In many centers, patients already are able to obtain routine care for standard low-risk ailments by e-visits, which can be managed by electronic communication. This format for care meets the time needs of the patient and is markedly more efficient for providers. E-visit patients typically are screened by physician extenders who use evidence-based protocols that allow prompt replies and electronic prescriptions. Organizations, such as Kaiser Permanente and the Veterans Affairs system have demonstrated that they can provide specialty care with the use of telemedicine and much more efficiently distribute expertise. These opportunities for care will be augmented by telehealth (patient-only interactions) in which detailed clinical education and instructions regarding conservative, patient-directed treatment can be provided. Patients will be able to go to their primary care physician’s office to have a consultation with a remote subspecialist, which would save time for both parties. The net effect of e-visits will free up office time for physicians to focus on patients who have more acute concerns and genuinely need to be seen face-to-face. As recent headlines at the Veterans Affairs system demonstrate, these transformative efforts must always be balanced with continuous quality improvement and oversight as organizations adapt to the future environment.
The large volume of health care data will allow providers to have a much more complete picture of the patient status. Digital information can be freely, quickly, and securely shared and available at the point of care. The clinicians have almost immediate access to laboratory and imaging results. They have an overview of all the notes and documents, regardless of setting, that are available as soon as other providers complete them. Vital signs and other data can be presented graphically, which has been shown to improve interpretation. Rules and alerts can be created to augment the provider’s ability to identify and avoid potential errors. Our own experience has been that, once providers get used to practicing with a much more robust view of the chart, they quickly become uncomfortable with the limited information of the paper chart.
Electronic medical records allow for the surveillance of health care and assessment of the degree of adherence to evidence-based protocols. This real-time, constant outcome, quality, and cost-effectiveness feedback allows for a more rapid pace of care improvement. By using ‘Big Data’ analysis of the risk-adjusted, complete detailed information, more effective and efficient care can be designed; even rare events, such as maternal death, can be tracked to see the effect of changes. Providers can review their own performance data, identify areas of variance in their practice, and receive helpful tips and comparison data for self-improvement. Provider performance data from large databases allow performance to be measured and fed back by a combination of meeting performance standards, outcome measures, and patient experience data rather than a subjective assessment. Not only will physicians use this data, but also public reporting of physician and hospital data has become common widespread and will become even more commonplace. Patients will be given the data to help guide their own health care decisions through direct comparison of costs, quality, and patient satisfaction. Both the baby-boomer and millennial generations have demanded similar transparency from other industries outside of health care, which will come increasingly important with the availability of purchasing exchanges laid out in the Affordable Care Act.
As the amount of information explodes with new advances in areas such as genomics and proteomics, the ability for human analysis will be challenged. In the digital future, the “genetic history” section of the chart will be a critical component to the provision of personal care. Constant screening by decision support tools will allow a “look over the shoulders” of providers to check their care and make sure that they see important trends or changing information. The digitization of information will enable us to take advantage of many of the disruptive clinical innovations.
Force 4: disruptive clinical innovations
Scientific advances that have the potential to change clinical practice radically and improve clinical outcomes are known as ‘disruptive clinical innovations.’ Indeed, many of these advances actually will change the delivery of health care, prevent or cure diseases, and reduce complications, which will markedly improve patient outcomes and cost. Of course, it will be essential that each new development be measured against the goals of the Triple Aim: (1) improve the health of the population, (2) obtain the best experience for the patient, and (3) control costs. Of course, the scope of development is broad and beyond the scope of this article, but we will discuss some of the more recent innovations in obstetrics and gynecology that have the potential to be quite disruptive.
Genomics and epigenomics
The human genome project, completed in 2003, identified >20,500 genes and illuminated tremendous possibilities for diagnosis and treatment. However, the task of linking genes to human diseases and conditions as well as research into variation and its impact on health has only begun. This new discipline, known as genomics, is the “branch of molecular biology concerned with the structure, function, evolution, and mapping of genomes.” The technologic advancements in equipment to analyze genetic material has allowed for rapid analysis at lowered costs. The advancements allow incredible diagnostic and therapeutic advancements. More recently, scientists have discovered that 90% of “dark matter” DNA contains the switches for these genes, which explains how control could lead to expression or lead to problems such as cancerous growth. The field of epigenetics, “the study of changes in organisms caused by modifications of gene expression rather than alteration of the genetic code,” is in its infancy. As we begin to appreciate the “on-off” switches of our genome, we will better understand how individuals can have the same genes and yet not the same phenotype and expressed disorders.
Genetic advancements may lead to earlier, less invasive and more accurate diagnoses. Recently, applications such as noninvasive prenatal diagnostic techniques have become available to analyze free fetal DNA strands that float in maternal blood in early pregnancy. Analysis by massive number sequence analysis and single nucleotide polymorphism analysis have led to tests that reliably can detect (sensitivity, >99%; false positive rate, <0.5%) trisomy 21, 18, and 13 and sex chromosomal disorders. As these results are validated in low risk populations, it is clear that they likely will replace hormonal-based screening (sensitivity, 80-85%; false positive rate, 3-5%). This transition markedly will reduce invasive sample testing and result in the lowering of procedure-related losses. In addition, the number of diagnostic ultrasound scans for ultrasound markers will fall. The net effect should be a reduction in “decision points” at which patients are given equivocal information and costs ( Figure ), therefore meeting the goals of the Triple Aim. Additional evidence of the potential of genomics was demonstrated in 2012 when analysis of maternal blood and paternal saliva yielded the entire fetal genome in an Italian cystic fibrosis study. These studies suggest that we will also be able to analyze single gene defects in a noninvasive fashion.
In gynecologic care, genomic techniques may also lead to noninvasive testing and improved screening. Next-generation DNA testing of stool samples has been shown to correctly identify 85% of polyps and colorectal cancers. Although not considered a diagnostic test, such testing could replace costly, unpopular (<70% compliance), and invasive tests like screening colonoscopy. The net effect may improve population screening as increased numbers of patients become compliant with “mailing in” a stool specimen rather than scheduling a colonoscopy. An additional gynecologic application of such DNA screening is in the detection of gynecologic malignancies. DNA probe testing has been performed on routine Papanicolaou test specimens and has been shown to detect 100% of endometrial cancers and 41% of ovarian cancers. The reader should expect an explosion of similar tests for other common malignancies from a variety of sources.
Genomic/epigenomic testing will also lead to the ability to design patient-specific tailored therapy. An explosion of identified genes like BRCA1/2 will help identify patients who should receive more timely interventions that are designed specifically for their unique genome. Choosing the most effective drug, such as which type of statin for hypercholesterolemia based on the presence of certain genotypes, can result in improved responses to medications. Ma et al found that it was necessary to adjust the dosage of Plavix based on the variant alleles in the patient’s genome. With the advent of multiarray genomic testing, patients could be screened for hundreds of such genes in the future, and precise medications could be prescribed to be most effective in that patient. Last, identification of specific “tumor-producing genes” will lead to drugs that could be targeted towards these cancerous tissues to “switch off” their anaplastic growth. Success will not be without challenges because clonal evolution and genetic instability of cancers and bacteria are known to occur.
Computer-aided diagnosis
Computer-aided diagnosis will also expand with the digitization of clinical information. Microsoft research laboratories in the United Kingdom have demonstrated algorithms for reading computed tomography and magnetic resonance images. Such advances will lead to ultrasound machines in which algorithms can be run on digitized volumes to obtain biometrics and to screen fetal anatomy. This ability should improve accuracy and, coupled with remote reading, reduce the human workforce needed for ultrasound screening. This will allow an expert who can read ultrasound scans to review images much more rapidly and accurately in the same manner that mammographers improved readings with the addition of computer-aided reading. Coupled with traditional telehealth communication video conferencing, this will make detailed imaging more widely available to patients in remote settings and should reduce imaging times. Application of these techniques to ultrasound scanning will allow for more accurate diagnosis; the net effect should be a lowering of undiagnosed anomalies and reduced costs per scan.
Minimally invasive therapies
Surgery will likely continue the trend towards minimally invasive techniques. Current controversy related to robotic surgery aside, the future discussion will be over how to perform the least invasive technique to provide maximal surgical outcome with minimal disruption of the patient’s life. This trend will be driven by patient satisfaction and payment reform that incorporates ‘disability time’ under total cost of care. Advances in equipment and market pressures will make the technology more cost-effective than current equipment. Advanced surgical techniques will be performed only by surgeons who do sufficient volume to maintain expertise. Hospitalists will take over many of the floor functions, which will free these surgeons to spend more time in the operating room.
Operative techniques will be augmented by better preoperative imaging and intraoperative use of dyes and markers that highlight tumors and lymph nodes. These techniques should reduce operative times and costs. Teleconferencing should allow for routine intraoperative consultation from remote experts for unexpected cases and those cases in which moving the patient is not possible. In addition to surgical techniques, invasive radiologic intervention and less invasive techniques such as hysteroscopic procedures and ablative techniques will allow for less costs and quicker patient recovery. Most fellowship programs are training new graduates in these surgical techniques, and it will be up to comparative effectiveness research to elucidate which procedures are the most effective and cost-efficient.
Stem-cell therapy and regenerative therapy
In addition to these advances, recent discoveries in basic science suggest that advanced genetic therapies that replace defective genes or turn off/on tumor promoter/suppressor genes offer hope that genetic abnormalities or translational errors can be corrected and can cure diseases altogether. Stem-cell therapies for diseases such as sickle cell anemia and other hemoglobinopathies can be given to fetuses and newborn infants and may correct defects before the children are affected. In utero surgical corrections may prevent long-term damage and chronic health problems that can reduce patient suffering and health care costs that are related to these problems. In urogynecology, the science of building stem-cell regenerated organs, such as urinary bladders, offers great hope for replacement organs.
Regardless of their promise, the success of these techniques will be determined by their efficacy and benefit as measured by the Triple Aim goals of improving the health of a population, enhancing the patient experience, and controlling costs. The transitional forces are all linked together and must occur in an orchestrated fashion. For example, payment reform must reward better usage of efficient digital medicine and new technology that provides cost-effective care with better outcomes for patients. Care redesign must incorporate the new technology for maximum efficiency as we see in the manufacturing and service sectors. When used together, the benefits will multiply and accelerate the process of improvement.
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