Dr. Paul Szotek of the Indiana Hernia Center in Carmel, Indiana, has some very strong feelings about what he calls the loss of the doctor-patient relationship.

THE PROBLEM

The corporate takeover of healthcare and the exodus of physicians from private practice into employed positions, combined with sub-par deployment of electronic health records and patient portals, has resulted in increasing patient and physician dissatisfaction with the current healthcare delivery model, he contended.

As the employed model has grown, physicians have increasingly lost autonomy to deliver care to their patients in a manner that optimizes the doctor-patient relationship, he said. As a result, he continued, the industry continues to spiral away from the healthcare experience of old. It is seeing patients search for doctors like they do local coffee shops, restaurants or hotels.

Most patients are searching the web to research both their conditions and their potential surgeons prior to consultation, Szotek said. He saw clearly that in order to be successful in private practice, he would need to deliver hernia care in a completely new manner.

"As I conceptualized my launch of the Indiana Hernia Center in the face of all the developing barriers to private practice entry, it was clear that we would need a disruptive Uber-like model to deliver low-overheard, efficient, quality care that would revive the doctor-patient relationship and generate a web presence second to none.

"In an effort to determine the best way to do this, I laid out a focused factory-delivery care model for hernia repair and evaluated the bottlenecks that caused the most dissatisfaction," he continued. "Like most dissatisfaction, it came down to poor communication nearly every step of the way, whether it be between myself and the patient, staff and the patient, or hospital and the patient."

From this he and his team laid out their core values for the business: "Every patient, every time. Doctor-patient-team relationship. Tech disruption for patients, not of patients. Your hernia, your choice. Experience. Focus. Results."

"With these core values in mind, we set out to find a solution that could disrupt the current delivery care model patients are used to and reinvent it using a tech-friendly solution that would meet all our core values and provide a better experience for patients across the continuum of care," he said.

PROPOSAL

The Indiana Hernia Center turned to health IT vendor Klara to help power its ideals.

"The purpose of implementation of Klara was to bring back the one-on-one relationship of the past between doctor and patient that has eroded with the implementation of healthcare technology and break down the communication barriers that cause dissatisfaction along the hernia care delivery pathway," Szotek explained.

"A key point of healthcare technology is adoption. So we looked for a solution that did not require office staff to train the full range of patients on how to use the technology, and rather leave that up to Apple, Samsung, Google, etc.," he continued.

"This was the key, as we have tried to launch clunky apps in the past through various EHRs that failed miserably with secondary to poor user experience."

In fact, one of the biggest struggles with EHR-based portals is adoption, and the best only get into the 60-75% range, he added.

With user adoption at the forefront of the team's search, it became clear that Klara was one of the only solutions at the time that could deliver both the communication needs the team desired, as well as a superior user experience that would drive adoption, he said.

MEETING THE CHALLENGE

Indiana Hernia Center strives to provide every patient with the same high-quality experience every time. When Szotek was designing the practice, it was clear that most dissatisfaction revolved around the initial experience with getting an appointment and that "first impression."

"I realized in order to deliver the same experience every time, I would need to control the narrative from the beginning. Yet most physicians are completely removed from this most important step and employed physicians have been taken out of this process altogether," he said.

"Instead of hiring more high-turnover positions, we deployed Klara to take over the initial experience and I defined it by the implementation and refined it so that every single patient gets the same experience without the variability introduced by staff turnover."

Klara allows pre-programmed "hot text" so that everyone gets the same welcome message and same narrative no matter who is on the back-end pushing the button, and gives Szotek the peace of mind that his patients are getting the user experience he desires.

The core value at the center of the problem redefined as the doctor-patient relationship now goes beyond just the doctor and patient in modern healthcare, he insisted. More important, he determined that most dissatisfaction generating negative reviews is centered not on the physician, but on the ancillary providers. The team wanted a solution to rectify this and build the entire doctor-patient-team relationship.

"Klara provided this, as there [are] patient-facing secure messaging and staff-doctor-facing messaging within the same chain," he explained. "With this, I can monitor all communication with patients in real time, intervene when needed, and correct information that the patient gets that is not standardized. My staff knows to tag me in any questions that are outside the norm so the answer comes from me. This builds trust for patients, as I am directly involved in their care and giving them accurate information 24/7."

"Klara, in combination with our shared decision-making process, has consistently been the source of positive feedback we see in our Google reviews, and breaking the 100-review barrier while maintaining a 4.9 rating."

Dr. Paul Szotek, Indiana Hernia Center

The integration of Szotek in real time into daily communication with patients has been one of the biggest positives of the Klara deployment, he noted.

The deployment of healthcare IT has been less than optimal. Most patients feel that the technology is pushing them away and disrupting their normal expectations of the healthcare experience, Szotek said.

"They are correct, as cumbersome EHRs with difficult-to-use patient portals that require downloading separate apps – with difficult-to-remember passwords, not platform-agnostic, etc. – have been the norm in healthcare," he said.

"Klara changes that for our practice. Any patient who text-messages on a smartphone or has access to the Internet on any platform can use Klara. If they cannot, and have a family member that can help them, they can still utilize the platform with them as a guardian."

This has resulted in: saved time for Szotek's staff, who no longer have to tell the patient to download an app and show them how to set it up, a HIPAA-secure system that does not require separate log-ins, and a patient adoption rate of more than 90%, he stressed.

"Delivery of hernia care is becoming increasingly more complex as multiple techniques and reinforcement strategies evolve," he noted. "At the same time, the explosion of litigation surrounding hernia mesh has led to increasing patient education and demand for non-mesh-based hernia repair options.

"In fact, looking at SERP data for March of this year, there was a 50% increase compared to March of 2020 for the search term 'hernia repair without mesh.' This is something we predicted long ago because, through technology, our patients were comfortable asking questions as they came up. This differs from a typical consult where they feel more rushed and have one shot to ask all their questions."

As a result, Indiana Hernia Center offers a shared decision-making care model to provide options for these somewhat-informed, concerned patients, he explained.

"In shared decision-making, we present the full spectrum of techniques and repair materials, including more natural material alternatives," he said. "Klara plays a central role in educating patients on their options. This communication and education lead to another discovery, which we have since branded.

"We learned that, when patients were more completely informed, even those that did not want mesh, they were more likely to elect for a robotic minimally invasive repair with a more natural reinforced biologic mesh."

His team has termed this the "ReBAR" (Reinforced Biologic Augmented Repair) technique, leveraging TELA Bio's OviTex Reinforced Tissue Matrix.

"The ability to discuss directly with patients, and provide them with education videos around the different options using Klara, combined with the telehealth solution as patients from around the country seek out these more natural repairs, has driven unprecedented growth in my practice," Szotek reported.

"Today, we have patients coming to us asking specifically for a ReBAR repair."

On another front, one of the key drivers in the value-based care triple aim of healthcare is outcomes, Szotek pointed out.

"Klara allows us to follow patients in real time in an unprecedented manner and truly follow our results over time to allow us to provide our patients with the consumer value they deserve," he said.

"Further, deployment of Klara within the practice has been across the entire spectrum of the hernia care delivery process: patient acquisition to patient registration, to patient consultation, to post-op care delivery, to long-term follow-up and building practice growth through an Internet presence."

When patients go to Indiana Hernia Center's website, they sign up directly through a Klara widget that then activates the system. If they call instead, they activate the system. Once they activate the system, they get a text message to start the registration process. At the same time, the team is notified that a patient is trying to register/has a question by notifications on their mobile devices.

The first available staff member can thus respond instantly. Often that is Szotek, the surgeon, which immediately shocks and comforts the patient at the same time, since they are not used to such an experience with the doctor, he said.

This immediately redefines the doctor-patient relationship as patients see it in comparison to their other interactions with corporate-based physicians who do not have such an implementation, or have multiple phone-chain barriers that just frustrate the patient and degrade the experience from the beginning, he said.

This immediate enhanced patient satisfaction and personalized care establishes the new doctor-patient relationship from the onset and builds trust in the practice, he added. Ultimately, this will translate downstream into a positive web presence, he said.

Klara delivers a mobile-friendly registration package that allows the patient to upload their credentials, insurance, medical history and, often, a picture of the hernia within about five minutes from start to finish. In addition, the new patient form that is completely mobile-friendly has built-in predictive algorithms that are able to determine all the information the team needs ahead of time to decide if there is more imaging/testing that will be required to care for this patient.

"If there is, we order it ahead of time and I can triage patients more efficiently, so to optimize their time without them sitting in the office filling out paperwork, or coming and waiting, only to be told they need to have a test and come back for a second appointment," Szotek explained.

"Not wasting our patients' time has generated much positive satisfaction.

"And Klara provides a seamless telehealth solution that I can utilize with a flexible schedule for patients at their convenience to share screens and go through imaging in detail with them," he added. "In doing so, I am not confined to short office-visit windows and can truly spend the time patients desire to get their questions answered, and for them to understand their condition and make an informed decision about their care."

Klara enables the practice to deliver a delightful customer experience that aligns with the preferences of today's mobile-first patient, Szotek said.

"I have to perform a great surgery, but Klara allows me to engage with my patients more efficiently. That includes virtual consultations, ordering imaging, diagnosing, pre-op protocols, and capturing and posting reviews to my website," he said. "This consistent process loop allows me to grow my practice by offering a better customer experience."

RESULTS

"Klara, in combination with our shared decision-making process providing more attractive options for engaged, inquiring patients, one of which is a more natural minimally invasive robotic ReBAR with TELA Bio's OviTex, has consistently been the source of positive feedback we see in our Google reviews, and breaking the 100-review barrier while maintaining a 4.9 rating," Szotek said.

"Probably the ultimate metric in this environment is we are still in business, despite it being said we could not do it on our own. Despite it being said we would not last, despite all the other naysayers, we have transformed an Uber model of being the largest deliverer of a service with only a digital footprint into the largest deliverer of hernia care in Indiana, leveraging Klara as the driving force behind the word-of-mouth marketing that is growing to a roar among patients seeking a better doctor-patient experience and more natural minimally invasive hernia repairs."

Looking year after year from the launch of Klara in the practice in 2017 to today, the average number of new patient consultations has risen from about 10 per month to 37 on average, distributed over all days of the week, versus the original model of only seeing patients in an office setting one day a week.

"Similarly, we have gone from an average of approximately nine surgical cases per month, with only two to three being robotic minimally invasive repairs, to averaging 24 surgical cases per month and 18 of them being robotic, with the majority being robotic ReBAR repairs using OviTex for patients countrywide. We recently did a bilateral inguinal ReBAR in a patient who traveled from a Native American reservation in Arizona."

ADVICE FOR OTHERS

"I would evaluate the entire delivery care model and choose a technology that alleviates the largest number of bottlenecks and miscommunications, that is easily adoptable and does not require a large amount of person-time training patients how to use the technology," Szotek advised.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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