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Most physicians spend more time fighting their software than seeing patients, and piling on new tools has not fixed it. Grace E. Terrell, a physician executive, argues that decades of layering electronic health records, population health tools, remote patient monitoring, and now AI onto sixty-year-old billing infrastructure has produced a Frankenstein stack that burns out clinicians and harms patients. This episode is based on her article “Connected health care workflows: From chore to core patient care,” published on KevinMD. You will hear why layering new tools on old infrastructure keeps failing, how prior authorization became an arms race, and what a genuinely connected workflow would feel like for a clinician evaluating a patient with suspected spinal abscess. You will also learn the one question to ask any vendor pitching a new tool, and why her company’s CIO believes EHRs themselves may not survive the next five years. Listen for a concrete path from chore to core patient care.

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Transcript

Kevin Pho: Hi, and welcome to the show, subscribe at KevinMD.com/podcast. Today we welcome back Grace Terrell. She’s a physician executive. Today’s KevinMD article is “Connected health care workflows: From chore to core patient care.” Grace, welcome back to the show.

Grace E. Terrell: Thank you. Good to be here.

Kevin Pho: All right, so we were just talking offline. You were on a little bit less than a year ago. Just briefly reintroduce yourself and then jump right into the article that you shared with us today on KevinMD.

Grace E. Terrell: Sure. Absolutely. So I’m Grace Terrell, and as you said, I’m a physician executive. My current role is chief medical officer at IKS Health, the role that I’ve had for about four years, but I’ve done a lot of other things in health care. I’ve run two large multi-specialty medical practices in my career and even done a genomics startup in whole genome sequencing.

But if you look at the trajectory of my career, I have been a practicing internist the entire time. And the reason I am at IKS Health actually today with my eclectic career, I would say, is because I think it has a significant chance of actually solving some of the last-mile wicked problems in health care. And so, anyway, I’d be happy to talk to you about that in more detail this morning.

Kevin Pho: All right, your KevinMD article is “Connected health care workflows: From chore to core patient care.” For those who didn’t get a chance to read your article, tell us what it’s about.

Grace E. Terrell: So if you think about all the ways that we actually deliver health care now, and I’ll use an ambulatory example. There’s been all this electronic tools that have been added to us through the years. In my experience, having practiced I guess about 34 years now, is it has made nothing better. There are certain things that are certainly great about being able to have access to electronic health records. I think not only I but many other people on your podcasts through the years and in your articles have talked about just the burden and the burnout and all of that, but the problem underneath that is related to our technology and the way that it’s actually been designed that is not human-centered and isn’t focused on actually solving for a lot of things.

So I think of health care technology as being in five stages. The first was practice management systems, billing, collecting, scheduling, claims adjudication. It’s 60-year-old technology. And on top of that we put transactional EHRs that were about individual patient stuff. And then we dabbled a little bit and added a little bit of population health. On top of that, we’re starting to talk about longitudinal care in different ways with remote patient monitoring. We were bringing the internet of things out, and then of course now we’ve got AI that’s sort of shaking everything up.

If you look at the problem though, we just layered all those things on old technology, one after the other, and so much of what’s been created have been individual point-solution tools that have been about solving individual friction points in the patient journey, in the physician workflow, in the administrative workflow. And so a lot of our cost, a lot of the burnout, a lot of the problems that we face actually trying to be good doctors is, in my opinion, built around that infrastructure.

So the way that I am imagining this in my article is to think about what a connected workflow would look like and how it would be different. So an example that I believe I used in that article is about a patient called James Smith or Doe or something. I wanted to create a typical scenario that might be seen by both a specialist but in primary care. So let’s just imagine a woman in her forties who has low back pain. She goes to a primary care physician, doesn’t get better, and she gets referred to an orthopedic surgeon. Well, in the one that I imagine, she gives a little bit of an unusual history, and there’s a little bit in the information that comes to that orthopedic surgeon. So she’s had some shaking chills and her white count’s up a little bit. And during the physical exam, there is some point tenderness in the lower spine.

So for those of you listening who are physicians, what ought to be going through your mind is, oh, this isn’t just going to be a musculoskeletal back pain problem. This is something that could be an acute medical emergency. She could have a spinal abscess. And that’s a whole different workflow trajectory. But within the context of that, actually what we have to do from all the referral authorization just to get the patient to the orthopedic surgeon, the eligibility and benefits, the pertinent history, medical history of the patient, the studies are individual point solutions that somehow have to get to this person who has to review it ahead of time.

Then after that there has to be other types of processes that occur that maybe, let’s say that a stat MRI is now needed to look for that spinal abscess. Well, the prior authorization types of processes are not very easy to do. And in an emergency that is almost a crapshoot sometimes, whether you’re going to be able to get it on time, where the patient’s going to be stuck with a big bill. And then of course, after that you’ve got all the coding that has to be right, you have to get all that stuff right, you have to drop the bill, and eventually maybe down the road, you’re going to get paid.

That is not a connected workflow. There’s all sorts of pieces and parts to it that we deal with every day. And it’s these interdigitated but not integrated forms of technology, with the workflows as part of it. So when I’m talking about a connected workflow, what I’m talking about is solutions that are looking much more holistically and comprehensively around that. So imagine both using some of the newer types of AI technologies that are interfacing in different ways with the technologies that we already have, such that it is almost a seamless process. That clinician is able to concentrate on the patient, has the right information ahead of time, the right things were done in terms of getting the referrals done in a seamless fashion. You don’t have to think about what the insurance necessarily is. You can just concentrate on practicing medicine. You can do something that’s evidence-based and get it done efficiently. That sounds like nirvana. With the new technologies we have, it’s possible.

Kevin Pho: So let’s go back and unpack something we said before we talk about these solutions and technologies. How do we get to this point? Why is it that health care and hospital systems, they like to pile on solutions from different vendors without fixing the fragmentation issue first?

Grace E. Terrell: Well, I think a lot of it has to do with just the high cost of technology, and you sort of get stuck. You get kind of caught by the technology that you’re in at the time. And we’ve built upon those old systems for better, for worse, maybe because our payment system didn’t change. I’m an advocate for thinking about payment policy differences in this too. And so the new technologies ended up being superimposed on old systems.

I mean, if you look at the health systems that are out there, billions and billions and billions of dollars have been spent on our current legacy systems. There’s a lot of policy issues around that have caused some of it, related to data blocking so that we can’t actually get to some of the new solutions because there’s information blocking. There’s sometimes HIPAA, etc., used as an excuse. And so it’s been very hard for some of the innovators in the health care ecosystem to sort of break through what is a very structured thing. That’s partly the result of our complicated payment process, in my opinion.

Kevin Pho: And in terms of care to the patient, talk to us about how these fragmented systems can affect patient care downstream.

Grace E. Terrell: Well, just in the example I gave, every single one of them was a risk point to the patient. So whether it’s all the hassle around the insurance eligibility, the access to the specialist in a timely manner, whether it’s getting the right information to that specialist. When the specialists need it and not a lot of other stuff that they’re clicking through an EHR a thousand times or looking at some sort of fax document. So part of it is just the timeliness of it.

And then the other aspect of it is the aspects of the timeliness of getting the right study. In this case, in my example, I used an MRI because it is important to be parsimonious with MRIs, but sometimes it’s really important to have an MRI. So the patient may have delay in care, the patient may not get the care if there’s just a lot of administrative burden in place. And the patient quite often, if it’s not done right, may be left with a lot of financial burden as a result of studies that did not get approval. And so there’s potential harm for the patients along all of this. And I think you’re correct to be focused on the patient aspects of this.

Kevin Pho: In your article, you point to prior authorization as such an important place when it comes to rethinking workflow design. Why start there?

Grace E. Terrell: Well, I don’t know how old you are, but when I was a kid I loved Mad Magazine. And if you remember Mad Magazine, for those of you that do, in the little margins, there were Spy vs. Spy, which were the, it was a sort of a metaphor of the Soviet Union versus the U.S., but it was these little white spies and these little black spies that were fighting each other throughout the magazine, and one would come up with a bomb and the other would come up with something, a bigger bomb. And it was a metaphor for what I believe has happened in prior authorization, which is we’ve had a system in place where payers appropriately are trying to do something about overutilization, which does exist, and have created complexity for the clinicians that are trying to get studies done, such that there is just massive burden that slows the process down.

Now there’s a study that is out there, everybody’s quoting right now, saying that the new technology, AI, is just going to be a Spy vs. Spy opportunity out there, it is just going to get worse and worse and jack up documentation costs and all that. I actually don’t believe that. I believe that if there’s a solution out there that can actually create seamless, appropriate, medically appropriate authorizations for everything that’s needed, then that ought to, if it’s properly designed, take burden off the clinicians, it ought to take burden off the payers who are also spending a lot on this, and ultimately be better for the patients. It may require some payment reform to do that, but I think irrespective of payment reform, there is the opportunity in new technology for there to be seamless understanding of, is it medically necessary, medically appropriate, therefore it ought to be done. Does it meet their benefits? That’s what prior auth I thought would be doing.

Kevin Pho: So we have all these hospitals and medical systems that have a metaphorical Frankenstein of legacy systems and programs patched onto one another. So how can we sort through all this, and if we were to have the goal of a connected workflow, where can hospitals start on the road to that vision?

Grace E. Terrell: One way of thinking about it is to get out of the solution for everything being point solutions or the systems of record. We’ve used the electronic medical record to sort of be the structure that all things seem to have to be united with, and get to a system of action. And by a system of action, it means let’s look at these workflows that need to be done. Can we come up with comprehensive technology that actually supersedes, with some of the new concepts that are out there with predictive analytics, with AI, with other things, that actually get out of the Frankenstein and do it in a way that, the word platform is sometimes overused, but in its real use, in its real definition, it’s about having what you need when you need it in one place, as opposed to, in a connected workflow, which is the component of it that I think is important.

So if you think about this morning, I’ve flown in from Washington, D.C. back to North Carolina, and I used Uber. That’s a connected workflow. I scheduled the thing yesterday. It asked me immediately what time I wanted at the airport. It told me what time it was going to be there. It let me know what time it was going to be there. It took my payment easily. I was able to tip the driver easily, and that’s a connected workflow. That’s not what health care ever feels like for those of us that practice medicine. And that’s what we need to build. We can do that by looking at that as the bogey that we get to and then build technology around it. I think it’s becoming increasingly less expensive to do that.

Kevin Pho: What would clinicians notice first if connected workflows were actually working well?

Grace E. Terrell: I think that they would notice that they’re actually spending more time with patients and less time with administrative burden. They may be able to see more patients, but feel like they’ve had an easier, more fulfilling day. They may feel that they don’t have fits of anger over trying to justify a test that they know the patient needs, because that seamless workflow has made that easy for them. They may experience less disruptions in their day. And they may stop spending all their time looking at screens.

Kevin Pho: So for those hospital CMIOs that may be listening to you now and they get pitched and get presentations from IT vendors all the time, tell us the questions they need to ask themselves if they want to get off that path of Frankenstein-ing systems and building upon legacy solutions. What are some questions they need to ask themselves before evaluating?

Grace E. Terrell: Great question, Kevin. I would say that the first things that they need to ask have to do with what they’re actually solving for. Is it a single individual problem or something bigger? How does it connect into Frankenstein, as you talk about it? What data do they need to solve that? And then you need to ask them to walk through the entire workflow so that you can actually understand what their particular solution does as it relates to the clinician’s actual lived experience or the patient’s lived experience. And if they can’t do that, just walk away, because they don’t have an overall understanding of the ecosystem.

If somebody comes in and is talking about a more comprehensive way of thinking about it, then I believe they should really get into the same types of questions, but have them really talk about how do they solve for the fact that the legacy systems are still there even as they’re looking at doing something that’s more comprehensive. And those are very important questions for the CIOs, for the CMIOs to understand.

I would suggest that for those making financial decisions, those making contractual decisions, that having clinicians, clinician leaders, as part of the discussion can be useful. Because quite often technology is imposed on us as opposed to something that we actually could find useful in our day-to-day experience.

Kevin Pho: Talk to us about some of the trends that you see coming in the near future when it comes to these connected workflows. You mentioned things like AI. I’m interested in hearing your perspective on large EMR systems, like say Epic, because a lot of systems use Epic, and Epic has their own solutions, and their solution may be different from yours in terms of connected workflows. What’s your perspective in terms of what we can look forward to going forward?

Grace E. Terrell: So if you talk to the chief information officer of my company, he would say that EHRs may be obsolete in five years because of what AI could possibly do in terms of delivering information in ways that are more appropriate. The problem that the EHRs have is that they were built for transactional, individual transactional medicine. Putting clinical documentation on something to get individual transactions paid for, whether it’s ambulatory procedure, hospital, or whatever. And that’s not what AI does or needs. AI is about the ability to have access to data that’s much less built and tied into those types of algorithms.

So the EHR companies may well morph into companies that are able to achieve that, but that’s not the way that they were built. And so right now many of them have a sort of way that they lock in the information that makes it difficult for the health systems that have access to it, for certainly for individual clinicians, folks in independent private practice, and most definitely the patients cannot get to broader ways of actually learning and adapting and benefiting from AI because the data has been captured in some of these old systems. So the future will be to those who are able to unlock it in ways that are safe from a privacy and security point of view, but also at the level of massive data such that these new types of systems can be placed. They may do it, but it’s going to require them to build some things that they aren’t right now.

Kevin Pho: We’re talking to Grace Terrell. She’s a physician executive. Today’s KevinMD article is “Connected health care workflows: From chore to core patient care.” Grace, as always, what are some take-home messages they want to leave with the KevinMD audience?

Grace E. Terrell: It is about the patient. It’s about the patient. It’s about the patient. Think about a future where you’re able to actually be about the patient again, and that future has to do with getting the workflows right and connected technologies as opposed to individual point solutions.

Kevin Pho: Grace, as always, thank you so much for sharing your insight and perspective, and thanks again for coming back on the show.

Grace E. Terrell: My pleasure. Have a great day.