Insights with Richard Santore, MD: Tech vs. Talk

Dr. Rich Santore is one of Avant-garde Health’s advisors helping to drive the clinical strategies for our orthopedic service line analytics. A leading voice on orthopedics for over three decades, he has experienced the evolution of patient care and the introduction of technologies to improve the patient experience. He also understands that while medicine is about science, patient care is also about people. Dr. Santore shared his perspective on caring for patients in an era where technologies like electronic medical records, advanced analytics and artificial intelligence are impacting health care.

How do you approach your relationship with your patients?

One of the things I do is spend up to an hour or more with a new patient to sort out what the diagnosis is. The most important element is to listen respectfully as patients describe their unique concerns and symptoms in their own words. I don’t allow a computer in the office with me when I am seeing a patient because I want 100% of the time devoted to eye to eye contact as we talk. The electronic medical record was imposed by the federal government on the medical profession before a reliable product for the purpose had been developed. Not only has this resulted in an average drop in productivity of around thirty percent (30%) for most doctors and clinics, but it has adversely affected the nature of the doctor patient encounter. Patients deeply resent the doctor’s focus on data entry into a computer or iPad or smart phone, rather than what used to be important time for eye to eye contact and attentive listening. Now with that being said, I rely on quantitative analysis, case data and evidence to help me make the best decisions for my patients, but I balance it with an understanding that my patients are people first and not numbers. Careful listening guides my follow-up questions during the encounter and leads to a sensible plan for further tests, consultations and whatever else is needed to establish an accurate diagnosis and to propose appropriate options for treatment.

Having real-time access to data is key to making sure my patients are getting optimized, cost-effective care. I am responsible for talking through with my patients the journey they are about to take and for making them feel comfortable with the process and actually eager to improve their quality of life. Connecting with my patients on that level is what I love about my work. I never want that to change.

The thing I like the most about being a doctor is temporarily becoming a part of my patients’ lives and getting to know so many wonderful people personally and professionally. This has been one of the greatest sources of satisfaction to me as an orthopedic surgeon.

How does technology impact your relationship with patients?

No doubt, technology, specifically data technology, is changing health care. There are a variety of innovations that have emerged to improve the patient experience. For example, at a baseline level, online information can help them better understand their situation. Despite the drawbacks of consulting “Dr. Google”, patients are becoming better informed consumers of health care and access to information is making that possible. The issue becomes whether or not the information is credible. That’s why having connections with a trustworthy physician is so important and why it is imperative that physicians make ourselves available, and at the appropriate times during the care continuum, but always with an eye on reliability and efficiency.

The ability of a patient to send a quick picture of a wound or a rash via a smart phone directly to their doctor, or of a doctor to look at an x-ray, CT scan or MRI from home or any remote access are true game changers. The EMR, on the other hand, has disappointed greatly so far and has been detrimental to direct patient care efficiency. Pre-population of data fields on a progress note in a patient chart by nurses and attending physicians, as well as residents and interns and medical students, has made it virtually impossible to tell whether something in the chart is real, i.e. directly inputted by a live person, or whether it was pre-programmed to comply with regulations for reimbursement, but done by automatic entry, and repeated day after day during any given hospitalization. As an example, I was once shown the chart of a patient who had required an amputation of one leg. The nurses’ notes for five days after that reported that pulses, in both legs, were present and equal. This is but one example of the failure of the promise that Electronic Medical Records would increase the accuracy of documentation.

New technologies, including wearables and apps, can more effectively engage patients, for example reminding them of appointments or when to take medications. It may sound simplistic, but for a large population of patients, it’s necessary and it’s making a difference in outcomes; just look at the data.

Other technologies focused on data are becoming increasingly impactful. One thing EMRs do well is collect data on virtually everything entered into the system. With properly configured EMRs, we are collecting so many data points and aggregating information we never before documented. With the right software, the capabilities of which are rapidly evolving, the raw data can be turned into useful information. We’re at a tipping point where making the data actionable is standard operating procedure. As physicians, we always try to improve the way we do things. In the past, much of our effort was based on intuition or one experience from the past, or what we thought was the right thing to do. With data, we can make decisions based on evidence. We can change our behaviors based on positive trends. And in the end, we can improve patient care. For example, would we be discharging hip and knee patients to home on the day of surgery, or at most in between 1-2 days after surgery if analytics didn’t suggest improved outcomes? In orthopedics, analytics are driving our decisions and will lead to positive changes in Medicare guidelines such as elimination of the requirement for a minimum of two nights of hospitalization after a total hip or total knee and permission to do the surgery in free-standing out patient surgical centers, with same-day discharge home. How far we have come! In the mid-1970’s, patients were kept in the ICU for 48 hours after total hip replacement, then remained bedridden for five days and were ultimately discharged to a nursing home or home around fourteen (14) days after the surgery. In Japan in that era, patients stayed in the hospital for up to six weeks. No wonder that DVT was such a big issue in the early years of total hip replacement.

How do you see Big Data and technology shaping the future of patient care?

One of the reasons I have supported Avant-garde Health is because I believe in the value of analytics, and their approach is very unique. Big data alone is useless without meaningful analytics, i.e. specialized software, to measure, track, and benchmark the data. The information would simply not be actionable. Analytics, made possible by powerful software, are the future, and for many leading providers – the present.

As busy clinicians, we need easy and centralized access to the data. We need relevant insights that make sense of the data. We need to trust the data so we can use it to make us better physicians. With advanced analytics, especially those delving into costing and efficiency, we can accomplish this. More and more hospitals are implementing analytics solutions into their improvement initiatives – and achieving significant results. Soon these tools will be must haves, not nice to haves. Early adopters will have a significant advantage in the intensely competitive market for medical tourism that will be driven by data demonstrating high quality and favorable costs.

Why now? Costs for health care are rising in the U.S. faster than growth in the GDP. By 2025, US health care spending is projected to reach nearly 20% of GDP. I think with the political climate focused on health care reform – or the repeal of reform, we have an opportunity to be proactive outside of policy. The first step in managing costs is transparency into what we are actually spending, which is not always clear as it is in other industries. Most importantly, analytics that other successful industries use, like TDABC, make it clear.

When we understand at a granular level where the opportunities lie to increase efficiency and reduce costs, we can make improvements. When we document variation across teams in specific service lines, we can take action to reach high reliability. When we see what clinical approaches lead to better outcomes, we can implement a proven standard of care. Having a solution that provides clinical, financial, and operational analytics is going to help transform health care and ultimately improve the patient experience.

Richard Santore, MD is a Voluntary Clinical Professor of Orthopaedic Surgery at UCSD, President and CEO of Orthopaedic Medical Group of San Diego, the Founder and Co-Director of the San Diego Hip Preservation Center and the President of Santore Consulting, Inc. He is the past Chief of Staff of the 1,200 Physicians of Sharp Memorial Hospital in San Diego, where he led the medical staff during the implementation of the electronic medical record, the opening of a new hospital and a successful Joint Commission full review. He is a Harvard trained (Massachusetts General Hospital) orthopaedic surgeon who specializes in hip and knee surgery and is one of the world’s leading authorities on hip dysplasia and osteotomy surgery of the hip. He is a Past President of the American Association of Hip and Knee Surgeons, the California Orthopaedic Association, the Western Orthopaedic Association, and the San Diego Surgical Society, and is a member of the Hip Society, the Knee Society, the International Hip Society, the American College of Surgeons, AAOS, the Orthopaedic Research Society, and the American College of Physician Executives.