Raghu Santanam: On the front line for healthcare technology rollout

Raghu Santanam will be on sabbatical next year at the Mayo Clinic in Scottsdale, Arizona. The topic he is exploring could not be timelier. The health care reform legislation that requires hospitals, clinics and doctors to keep electronic medical records also mandates that patients be given what’s called “meaningful use” access. Santanam will be on the front line as Mayo rolls out a patient portal system for Arizona.

Raghu Santanam will be on sabbatical for one year beginning in fall 2012. During that time he’ll be working at the Mayo Clinic in Scottsdale, Arizona with medical practitioners, IT personnel and other academic researchers. The topic he is exploring could not be timelier. The health care reform legislation that requires hospitals, clinics and doctors to keep electronic medical records also mandates that patients be given what’s called “meaningful use” access. Santanam will be on the front line as Mayo rolls out a patient portal system for Arizona. It’s an opportunity to study the delivery of a new IT service, and to help adjust it as needed. Here’s Raghu with the background.

Transcript:

Santanam: In recent times, hospitals, as well as ambulatory clinics, have moved electronic medical records. That means, in sort of keeping paper-based information about patients, they’re now trying to store all of this information in electronic format including your laboratory results, the clinical encounters that you have with the medical providers, as well as any X-rays, et cetera. They want to store everything electronically so that it’s accessible not only at the primary provider’s office, but also in the context of care coordination when you go to specialists and other medical facilities or when you’re in a hospital.

Now that’s been going on for the last—actually a couple of decades, although a lot of activity happened in the last five or six years. Now that we have access to electronic medical records, it makes logical sense to then say, “Well can we provide patients with more information about their own health information?” That’s where this idea of patient portal comes in, where you expose the medical information that’s stored in their electronic medical records. I mean that is obviouslyone intent.

The second thing is that there are a lot of challenges in working with the physician’s office; getting appointments set, or having some doubts cleared with the physician, or getting some prescription refill requests through. There’s so many other messages that you want to exchange and communicate with the physician’s office, so that’s where again, patient portals, come into play with all these other administrative features that it can add in on top of just the basic medical information we can provide.

knowIT: How widely are patient portals being used right now? I guess that would depend on the adoption rate of electronic medical records, to begin with, and then how widely are patient portals used?

Santanam: Yes, and we are really in the early stages. Among the ambulatory clinics, it seems that I would say 10-12 percent range if not lower. In hospitals, there are only a few large systems that have been using patient portals for a while. I mean Kaiser Permanente is one of those that has all three million patients, I think, on their portal. Even there, I think nationally you could safely say that less than seven percent of the population probably has access to a full-fledged patient portal.

knowIT: In that seven percent, how well do patients use them or how often do patients actually use this tool?

Santanam: The results are mixed, and the literature actually talks about the most widely-used features. Among them is appointment requests, viewing the laboratory records or the results, and also, in some cases, some secure messaging with the physicians on prescription refills and things like that. It’s not extensively used and that’s what actually makes it an interesting area for me to research on.

It’s very early adaption and there are a lot of issues still unresolved, but at the same time, this is a critical juncture for the healthcare industry because of the HITECH Act (Health Information Technology for Economic and Clincial Health Act of 2009) that the government passed in the last couple of years about healthcare reform. One of the major aspects of healthcare reform is this “meaningful use” regulation that electronic medical records should be used in a meaningful way within the provider offices and hospitals. But also, some meaningful information has to be exposed to patients within a short amount of time, so we think they’re saying the next two-three years.

Therefore, a lot of providers are interested now in offering patient portals so they’re seriously thinking and initiatives are underway in many hospitals and provider offices. Still, these are the early days.

knowIT: Now I understand that the Mayo Clinic, here in Phoenix, presents a really fabulous opportunity for you to explore this area. Can you explain why?

Santanam: First of all, Mayo Clinic is a household name around the world, and it’s well known for the way it looks at patient outcomes and in the quality of care that it provides. Being at the facility at Mayo Clinic, and being engaged with their initiatives and patient portals is a great opportunity -- for anyone. More interestingly, Mayo Clinic recently started a wide-range of initiatives under an umbrella of THE Center For Health Services Delivery.

Now, that covers both the delivery of care, care coordination as well as, on the technology side, better patient engagement and shared-decision making. All in all, there’s a huge initiative underway at Mayo Clinic to improve patient outcomes. It’s juxtapositioned well with emergence of electronic medical records and as well as patient portals. So it makes it a very, very interesting context to both understand how patient portals will get used and, also, look at some interesting ways of offering patient portals such that the patient engagement can be measured. That’s really the goal of my sabbatical research as well.

knowIT: I understand that Mayo is phasing in patient portals? Is that correct?

Santanam: Yes it is. That’s what makes this an interesting opportunity because you can look into the before and after picture. What is going on before patient portals were introduced and what happened after we introduce certain features within the patient portals.

A couple of things that we have been discussing and seeing that they may be the right way to approach patient-portal rollout is:

1) consider social media usage which can help patients interact more with the clinicians at Mayo Clinic. As well as possibly in a safe way, interact with other patients who are Mayo Clinic patients. What we’re hoping to do in that context is maybe consider some specific scenarios; maybe diabetes management, or obesity management, or some other sort of a chronic disease context with care coordination and support from external entities that helps the patient manage the disease and maybe see improvement.

Engaging those patients in that sort of a setting is probably the most fruitful way to understand how social media can help improve patient outcomes. Because ultimately, even though one could look at patient portals as "Well, you know, it’s part of a mandate from the government, so let’s go and introduce it;" but a better way to think about it is to say that, “Hey, you know, patient portals now gives us an interesting way to enhance the services we provide.” Now how do we do it really well? That’s the approach Mayo Clinic is taking.

knowIT: I was reading your summary, and you indicated that the way the research is going to be done will be iterative. Can you explain what iterative means in this context? It’s such a great word!

Santanam: It is. In information systems research, what we have discovered over the years is that systems have unintended consequences. One cannot take a rigid approach to rolling out systems and its features to any population, but especially when you are dealing with a consumer context where there is a huge diversity of patients and users, you really have to carefully approach how you roll out the types of features in a patient portal.

knowIT: Because a patient portal, it’s not like you’re choosing a narrowly defined user group. This could be anybody—any kind of a person, any age, any occupation, all kinds of various abilities.

Santanam: And different needs, yes. Yeah.

knowIT: Different levels of familiarity with technology.

Santanam: Yes and that plays a big role as well. Some of the research that we have done over the past few years has shown that age is a big factor. The demand for health information itself is very different based on the type of consumer that you’re looking at. The health status of the patient can play a big role. Then there is also the family situation. Many consumers also want to manage the family information. There’s always a caregiver who would have a different sort of a need out of a patient portal than the patient. All these things are to be carefully considered when you design the features for the patient portal. Although what we’re doing in Mayo Clinic is to use the patient portal provided by a vendor; so it’s not designed from the ground up. It still allows you to configure it in different ways.

The issue is what is the good configuration and then it’s, of course, understanding that it’s a social technical system that there is not just the technology aspect, but it’s also how do we now get the buy-in from the medical providers and as well as the patient groups. Carefully understanding those angles is very important, so that’s the reason we think it should be iterative. Maybe the intent is to work with small groups, focused groups, of course, that maybe it says specific disease context.

These details still need to be worked out and that’s what we plan to do in the summer, but we will probably be focusing on some very specific chronic disease conditions. Then within that context understanding exactly what we need from a clinical perspective and then figuring out the rolling out of the process and the services associated with it.

knowIT: As a service is being rolled out, do you anticipate measuring what goes on and then maybe adjusting and trying a different version of it and measuring and sort of tweaking it like that?

Santanam: Exactly. That’s the approach that we’re taking. Again, the idea is to—one of the critical outcomes that we want to go after is patient engagement. In the medical literature, there are quite a few studies that have been done that shows that in chronic disease conditions, conformity to the care plan on the patient side is inconsistent. That a large percent of patients that don’t actually take the prescription that have been given, so compliance a big issue. Part of that is that engagement perspective. How do you actually keep the patient engaged in the care process? Then the second thing is this nebulous notion of shared-decision making because it means different things to different people.

There’s still a debate on what actually is shared-decision making. Very likely that depends on the person as well as the clinician because each one has a different notion of what that means. It’s very individualized, but even within that, if one can enhance the perception of the shared-decision making, as well as the engagement, then we moving probably towards better clinical outcomes.

knowIT: This seems to me like it’s a different approach to research than other kinds of academic research. Would you say that’s true? I mean this is a live data set rather than a collection of data that you have access to about an event that occurred in the past. Is that something new or exciting for you?

Santanam: It is really exciting. My research into the healthcare area over the past decade has mostly been focused on archival data. That means somebody already did some initiative, then they collected the data. Now you’re using that data to figure out what happened. Now that in itself is valuable. It was interesting, and we’ve done that, but it’s a different level of engagement on my own part when you’re actually doing the primary data collection. With actually an influence on how the system itself is being rolled out, so that is a rare opportunity.

You would only get that if you’re part of an institution, so that really is great, and it’s great to be in ASU at a time when ASU and Mayo Clinic have a strategic partnership. In fact, one of our ASU departments is now actually housed at the Mayo Clinic campus in Scottsdale. It’s the Biomedical Informatics Department.

I have some close engagement with faculty in that department as well. What that allows us to do is to have this really strong partnership with the group here, but it also gives us the opportunity to work with other Mayo Clinic locations. We’re already discussing plans of visiting the Rochester Mayo Clinic facility. Rochester facility is a little bit ahead of Scottsdale in terms of the patient portal. They have actually rolled out one extensive version. They’re also thinking seriously about social media. That means that there is ways for us to actually even collaborate on the patient portal, both here and as well as in Rochester, and get a richer perspective into how this works.

knowIT: You have the benefit of their experience as we’re creating what it’s going to be here in Arizona.

Santanam: Right.

knowIT: It’s very interesting. Do you have other ASU professors that are working with you on this?

Santanam: Yes, Benjamin Shao in our department. He’s worked with me over the years in the healthcare area. I have had a couple of Ph.D. students who worked with me on this topic and who continue to work with me on this. My hope is actually to engage another couple of Ph.D. students over the sabbatical year and get them excited about doing a dissertation on this topic. Because the way I’m looking at it, even though this is focused in the healthcare area, overall it fits into the trend of consumerization of IT.

The digital society that we live in today, that we now have to focus more and more on consumer-focused issues of information systems. I think in our field, over the past four or five decades, we have done great work looking at the role of information systems inside organizations. But I think now is a chance for us to look at how information systems engage consumers and, in turn, how consumers influence the development of information systems.

knowIT: Exactly. A lot of innovation is coming from that direction, isn’t it?

Santanam: Right, and that’s the reason you need to know this better; so that now we figure that out as to how those changes influence information systems within organizations. It takes a 180 degree change in terms of how we look at the role of the information systems within organizations as well as in society. It’s really a different paradigm to understanding information systems.

knowIT: That’s great. In closing, I wonder—I don’t think the non-academic public understands the real value of a sabbatical and what impact that has not only on your research stream but also on the department and the student. Can you express that a little bit? What is the value of the sabbatical?

Santanam: Yes, you know the true intent of the sabbatical is to enhance the institutional reputation and contribute to the stakeholders. Okay? When we think about sabbatical research—when I was writing it, I had to carefully consider how my sabbatical will enhance the research in my area. Then how it would enhance the reputation of the institution and the department, and how it would contribute to the community.

All these things had to be in place, and then you also have to show how it helps your teaching. How does it come back into the classroom? How does it help the students that you did all this research? In one sense, one can say, “Well, I’m just gonna continue doing whatever I’ve been doing,” and call that sabbatical research, but that’s not really how we evaluate it. Because what we say is, “What is it that you’re going to do differently that’s going to enhance our institutional reputation?” That’s the way we expect our faculty to write the sabbatical proposal, and those are the types of proposals that get funded. So it’s not just that you put in so many years, and you get the six-month or a one-year sabbatical.

By the way, so when you go on a one-year sabbatical, the expectation is that a part of your salary is funded by the institution that you’re going to.

knowIT: Oh I see.

Santanam: It now becomes a shared partnership with Mayo Clinic and ASU.

knowIT: Sure. Sure. I think you mentioned you’ve had a sabbatical before? Did you find it refreshing?

Santanam: It’s interesting you say that, but my first sabbatical, I look back, and I did great work but the one thing that I considered was a drawback effect was that I was just coming to my own office here and I felt that although it was good, and it was productive, it didn’t expand my horizons in terms of exploding something new in a different institution context. That’s what I worked towards in the next seven years, and I said, “Well I need to do something differently.” I’m glad that this worked out the way it did, because this gives that one year out of my office here that I spend in a different institutional context. That’s really exciting, and I think that it’s really invaluable in terms of how I can bring that experience back into my classroom, whether it’s undergraduate or graduate programs.

In fact, I’m also hoping to write a couple of case studies that would show, for example, how you would successfully roll out a patient portal; what are the issues that you encounter; and how do you address those from a managerial perspective.

knowIT: So maybe we could touch base throughout the year. That might be really interesting.

Santanam: Yes, and I look forward to coming back and sharing the research findings and publishing this research. I look forward to talking to you when I have some things that I can report.

knowIT: Great!

Santanam: Thanks, Liz.

knowIT: Well thanks very much.