THE DECADE OF THE NON-DOCTOR CLINICIAN TELESERVICES FOR BETTER HEALTH:

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1 TELESERVICES FOR BETTER HEALTH: THE DECADE OF THE NON-DOCTOR CLINICIAN Global Institute for Emerging Healthcare Practices The World Health Organization (WHO) has declared that 57 countries are currently facing a healthcare worker crisis. WHO estimates that 2,360,000 healthcare professionals and 1,890,000 health administrative support workers are needed in order to alleviate the shortage. Source: World Health Organization website see also Working Together for Health, World Health Organization, 2006 Healthcare organizations are facing a variety of serious workforce concerns. The biggest and most fundamental challenge is the shortage of skilled healthcare workers, including primary care physicians or general practitioners, nurses, and allied health professionals. Demand for care and services is on the rise globally, and underlying demographic factors indicate that that the pressure on healthcare workers will not likely to change or let up substantially until at least Key healthcare leaders and stakeholders are still determining what their strategy will be for alleviating the shortage. Other workforce concerns include healthcare worker job dissatisfaction, an aging healthcare workforce, the question of how to manage teams of multi-generational workers, and the question of how best to invest in human resources in the context of today s financial pressures and budgetary constraints. Addressing concerns like these may require organizations to revisit their management practices, offer more flexible and adaptable terms of employment, forge new partnerships with educational institutions, set up new joint ventures across sectors or with employers, work with government agencies, and more. 2,3 Healthcare technology is also playing a critical part in changing workforce dynamics. For example, as healthcare information is shared more widely across settings and clinicians, and as TeleServices become more integrated with traditional care pathways, roles and responsibilities in the workforce are evolving. In this new world of multiple constraints and pressures, organizations need to leverage technology to enable each healthcare worker to contribute as much as possible to the delivery of care. Some of the ways in which technology will change over the next decade will present new challenges, while other ways will present opportunities for mitigating some of the workforce pressures noted above. In this brief paper, we examine five ways in which technology and TeleServices will have an effect on healthcare workforce issues. TeleServices: Extending New Capabilities to New Settings TeleServices such as TeleCare, TeleHealth, TeleCoaching and TeleMedicine offer a new method for organizations to deliver care and services to patients outside the normal boundaries of traditional settings. In many ways, they are productivity enhancers that can improve communication, relieve clinicians of the need to travel, promote patient engagement, and help coordinate the actions and efforts of highly valuable and increasingly scarce healthcare workers. Today we are seeing the scope of TeleServices grow beyond traditional TeleMedicine. TeleServices can augment and extend the resources of a healthcare organization to patients regardless of physical location, keeping them healthy and reducing the long-term system burden. There are four main types of TeleServices, as summarized in Figure 1. TeleCare is the use of home-based remote monitoring, sensors and assisted living technologies to alert caregivers to potential patient issues. TeleHealth is the use of health tracking tools, mobile apps and other devices that help patients virtually check in with staff on a regular basis and address health issues before they get worse. TeleCoaching technologies facilitate patient self-management and patient education either through live sessions or with

2 Asynchronous Long-term condition monitoring Nurses triage data Step up/down care based on trends NOT an emergency service TELEHEALTH Assisted-living technologies Home based but increasingly mobile Remote monitoring TELECARE HELP TeleCare TeleHealth TeleMedicine TeleCoaching Synchronous Based on video conferencing Remote consultations and diagnosis Delivery of some therapy services TELEMEDICINE TELECOACHING Helping patients manage their conditions more effectively Use via phone, computer, interactive TV Link to dedicated self-care content Figure 1. The Four Main Types of TeleServices. For a detailed discussion of these definitions, see the first paper in the CSC series, TeleServices for Better Health automated feedback. Finally, TeleMedicine in this context refers primarily to real-time remote consultations with clinicians that essentially recreate the face-to-face experience between patient and doctor. As these TeleServices become more widely adopted and care becomes more distributed, the roles of some healthcare workers will be elevated. In particular, non-doctor clinicians will need to practice at the top of their license to meet rising demand in a time of increased constraints on capacity. Moreover, although teambased care will become more widespread, each team member will need to be a specialist at his or her set of tasks, and will need to acquire and maintain some minimum level of technical proficiency with the new tools and technologies of the trade. Five Ways in Which TeleServices Will Affect Healthcare Workforce Dynamics There are many ways in which TeleServices will affect, and be affected by, the dynamics of the healthcare workforce. Below we present five things for today s leading healthcare organizations to look out for: 1. Non-doctor clinicians will need to practice at the top of their licenses. The looming shortage of healthcare workers means that non-doctor clinicians will need to practice at the top of their licenses. This means performing the most advanced tasks for which one is certified, and pushing simpler tasks to less advanced workers. By doing this, nurses, nurse practitioners, home health workers, therapists and others can free up physicians to see more patients in traditional settings, as well as allow them to take on new roles, such as managers of patient-centered medical homes. Along the same lines, licensing and credentialing requirements are changing. For example, prescribing privileges are loosening in several countries including the United States and the United Kingdom. Increasingly, non-doctor clinicians, including different types of nurses and pharmacists, are gaining authorization to write and/or fill a wider range of prescriptions. TeleServices for Better Health: The Decade of the Non-Doctor Clinician 2

3 As more TeleServices are introduced, non-doctor healthcare workers will have an opportunity to take the lead in new areas. Physicians may find an efficient technology in TeleMedicine, where they can conduct a live consultation and bill accordingly. Nurses, on the other hand, could find themselves well-utilized in providing patient education and encouragement through TeleCoaching services and in reviewing patient-reported data and trends through TeleHealth services. As observers have noted, nurses are well-suited for such services because they are flexible, motivated and used to being at the forefront of change There will be an increased need for clinical staff to have and maintain proficiency with information technology and computers. At a time of strained hospital IT budgets and limited ability to hire new technicians and technical support staff, the growing sophistication of healthcare technologies means that there is an increased need for healthcare workers to have and maintain technical proficiency with the computers and equipment used in TeleServices. It will be increasingly expected that doctors, nurses and other caregivers will be capable of working most of the equipment themselves. This can be a challenge for certain older workers, some of whom are less comfortable with using computers and mobile devices. Organizations will need to be proactive in ensuring that all workers receive proper training. Fortunately, most of the technologies used in TeleServices are getting easier to use, despite the increase in their sophistication. Computers, cameras, devices and peripherals are now often wireless, relatively unobtrusive and occasionally selfconfiguring (i.e., plug-n-play ). In the past 2 to 3 years, the focus on good design and human-computer interaction has become intensified. Many of the technologies that are being used to deliver TeleServices are built upon the same consumer technologies (e.g., smartphones, webcams and televisions) that healthcare workers use in their personal lives. The bar for technical proficiency has been lowered, but openness to using new technologies has become imperative. Thus, while highperforming physicians and nurses do not need to be technological wizards, there is less and less room in health systems and large physician practices for those who are not willing to participate. (Indeed, some U.S. physicians nearing retirement age chose to quit medicine rather than adopt electronic health records when reimbursement penalties for non-use were introduced.) 3. Data literacy and quantitative skills that complement computers will become ever more valuable. Healthcare delivery is more closely measured and more performance-driven than ever before. New value-based payment models that penalize for readmissions mean organizations will be working to improve their outcomes at the same time they are being pressed by economic conditions to eliminate costs and reduce waste. The modern hospital and physician practice are awash in reports and raw data, but they often lack personnel with the quantitative skills to make good use of it. 5 It is not necessary for administrators, quality nurses and nurse managers to become statisticians, but some opportunities for improvement will only be visible to those who are comfortable with numbers and adept at mathematical reasoning. TeleServices are capable of generating enormous amounts of data. For example, TeleCare home monitoring equipment can provide near-continuous surveillance of a patient s home environment. TeleHealth medical devices and mobile apps can capture and report quantitative variables related to weight, blood glucose, physical activity and calorie consumption multiple times per day. Most of these data will be processed automatically and filtered by algorithms, but someone will still be needed to examine the aggregate data, identify trends and separate the signal from the noise. It is not yet known, for example, which patients respond best to which types of TeleServices, or what the optimal time is to intervene with a patient who is reporting a gradual decline. Computers increase the amount of information that each worker can monitor; workers who can monitor information effectively will be at a premium. 6 Responding quickly to patient-reported outcomes data and other feedback is how healthcare TeleServices for Better Health: The Decade of the Non-Doctor Clinician 3

4 delivery organizations will be able to achieve and maintain a competitive advantage. Quantitative skills will be necessary for determining program success, failure and return on investment. Unfortunately, these skills are not part of general medical training, so clinicians, doctors, nurses and others who are so inclined need to undertake their own self-directed education in these areas, or organizations will have to recognize this need and address it. The high-performing team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system. Source: Core Principles & Values of Effective Team- Based Health Care, Institute of Medicine, October Healthcare increasingly will be delivered by collaborative care teams working across distances. Modern medicine is exceedingly complex. With clinical practice guidelines evolving constantly and with patients increasingly seeing multiple caregivers and specialists for assorted chronic conditions, the ability to collaborate with others will become increasingly important. 7 More care will be delivered by interdisciplinary care teams, yet all of the members of the teams will not always be located in the same room. Individual caregivers will need to work together effectively in order to deliver a coordinated response to each patient s needs. Good communication among care team members will be critical to the successful scale-up of TeleServices. For example, a nurse monitoring a diabetic patient s self-reported TeleHealth data needs to have an efficient way to escalate her concern to the appropriate doctor should she detect a downturn in the patient s metrics. Or, to take a TeleCoaching example, a home health worker could invite a physical therapist into a videoconference if a patient raises a question about his discharge instructions. Organizations will need to provide an adequate communications infrastructure and tools, including electronic health records, secure messaging and likely, secure texting and mobile devices. Technology must be available to accommodate any type of worker to collaborate from virtually any location. At the same time, organizations need to understand potential issues with regard to licensing, certification and privileging. The rules for granting privileges and recognizing credentials are slowly becoming less of a barrier, but whereas in the past this was only a concern for a relatively small number of physicians, it could ensnare other members of the care team, including home health workers, who are more mobile than anyone else. 5. Greater patient engagement means healthcare workers will partner with patients, not just treat them. Patients have been one of the most chronically underutilized resources in all of healthcare delivery. Patients have long been seen as the object of clinicians care efforts rather than a potential participant in the process of care design and delivery. Getting patients engaged is important because the more involved they are, the better equipped they are to make healthy decisions. 8 Disengaged patients forget what they are supposed to be doing to stay healthy, and they may fail to follow directions or check in with their caregivers. As a consequence, disengaged patients don t get the benefit of better information and expert feedback. Some patients or health consumers are already well-informed, highly engaged and motivated. These individuals actively want to be a participant in their care and eagerly embrace new ways of working with their clinicians and caregivers. Patients who do well in a TeleServices-supported program may not need to come in for their next regularly scheduled in-person visit. These patients have become, in a sense, part of the healthcare workforce. From a workforce perspective, freeing up service capacity in this manner can enable healthcare workers to see other patients. TeleServices promote greater engagement by letting patients help to design and choose which tools they will use and how they will use them. With TeleServices, patients can become active participants in their care, rather than passive recipients. Using apps and home medical devices, they can track their conditions and send in their data and measurements for review. Patients who are not doing well can be scheduled for a TeleCoaching session or a regular visit before their condition worsens. Non-doctor clinicians and caregivers will need to bring patients along TeleServices for Better Health: The Decade of the Non-Doctor Clinician 4

5 in terms of providing health education and disseminating information to increase basic health literacy. Valuable new workforce skills will include the ability to use technology to educate and motivate patients at a distance, and to manage their questions and concerns. Summary As TeleServices continue to evolve, they will change traditional roles and responsibilities in a way that could help organizations meet and overcome workforce challenges, including those related to capacity concerns and rising costs. There is no onesize-fits-all model for how these programs and services should be implemented, but clearly they need to be in alignment with the organization s overall strategy and values. The roles of non-physician caregivers will become ever more critical as greater use of technology by patients at home and on the go generates more patient data and more potential points of intervention. Hospitals and health systems that recognize these workforce changes and adapt will be best able to get the most out of what TeleServices have to offer. About the Authors Jared Rhoads is a U.S.-based senior research specialist with CSC s Global Institute for Emerging Healthcare Practices, the research arm of CSC s Global Healthcare Group. John Ainge, MD, is an Australia-based clinical adviser in CSC s Global Healthcare Group. References 1 Retooling for an Aging America: Building the Health Care Workforce Institute of Medicine, April Policy Brief #13: How can telehealth help in the provision of integrated care? World Health Organization, The Aging Workforce: Challenges for the Health Care Industry Workforce, U.S. Department of Labor, March Should nurses be at the forefront of telehealth? The Guardian, January Harris, J. Data Is Useless Without the Skills to Analyze It, Harvard Business Review, September 13, Cowen, T. Average Is Over, Dutton Press, 2013, p.33 7 Core Principles & Values of Effective Team-Based Health Care, Institute of Medicine, October TeleServices for Better Health: Technology That Brings Healthcare to the Patient, CSC, October 2013 TeleServices for Better Health: The Decade of the Non-Doctor Clinician 5

6 Healthcare Group 3170 Fairview Park Drive Falls Church, VA Worldwide CSC Headquarters The Americas 3170 Fairview Park Drive Falls Church, VA United States Asia, Middle East, Africa 20 Anson Road #11-01 Twenty Anson Singapore Republic of Singapore Australia 26 Talavera Road Macquarie Park, NSW 2113 Australia +61(2) Central and Eastern Europe Abraham-Lincoln-Park Wiesbaden Germany Nordic and Baltic Region Retortvej 8 DK-2500 Valby Denmark South and West Europe Immeuble Balzac 10 place des Vosges Paris la Défense Cedex France UK and Ireland Region Royal Pavilion Wellesley Road Aldershot, Hampshire GU11 1PZ United Kingdom +44(0) Copyright 2013 Computer Sciences Corporation. All rights reserved December 2013 About CSC CSC is a global leader in next-generation IT services and solutions. The company s mission is to enable superior returns on our clients technology investments through best-in-class industry solutions, domain expertise and global scale. For more information, visit us at

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