The Quadruple Aim: Let's eat some cake.

The Triple Aim

In 2007, the IHI introduced the Triple Aim in reaction to debate for healthcare reform.  They defined a way to better deliver cost-effective healthcare to improve population health.  The Triple AIM focused on three critical objectives to achieve this goal:

  1. Improve the health of the defined population

  2. Enhance the patient care experience

  3. Reduce the per capita cost of care

As health systems began developing operational and clinical processes to implement these pillars, the industry started to identify a fourth component that was equally essential: improving healthcare workforce burnout and dissatisfaction.

The Quadruple AIM

First introduced by Dr. Bodenheimer in 2014, the 4th AIM was a topic that initially seemed controversial and “off-limits” to many traditionalists in the industry.  However, as panel sizes grew, EHR data entry increased, and physician shortages ensued, provider experience became essential to achieving the cost and quality outcomes outlined in the Triple Aim.  Bodenheimer recommended expanding the Triple Aim to the Quadruple Aim.  He emphasized the importance of improving the work-life of health care providers, including clinicians and staff.  

At the time the Quadruple aim was introduced, 46% of physicians were experiencing symptoms of burnout.  That number climbed steadily through 2016 to 51%.  Many doctors began reporting symptoms of clinical depression. Sadly, a significant deterrent to seeking medical help for depression is the social stigma and public “shaming” associated with the diagnosis.  The consequences are grave:  the American Foundation for Suicide Prevention reports that an estimated 300 physicians die each year from suicide.

Incorporating the 4th Aim

Today, there is widespread acceptance of the Quadruple AIM, with physician experience being the 4th objective.  The IHI has endorsed this model with the caveat that the core focus of the AIM remains on the patient.  Today, as more attention is given to the 4th AIM, some causes of physician burnout are revealed:

  1. Regulatory headaches

  2. Insurance barriers and to delivering care

  3. More complex and time-consuming licensure and certification requirements by specialty boards

  4. Increased non-clinical hours spent on administrative tasks

  5. Increased “clicking” in the EHR repeatable tasks created by the EHR

We have seen much traction in advancing physician experience with operational changes, and many health systems are now recognizing the 4th AIM as a core initiative for 2019.  

Technology to the Rescue

In addition to operational improvements, health systems have been turning to new technologies to close the gap in physician experience.  In the past 5 years alone, over $30B of venture capital has gone towards health tech innovation, and many of these solutions improve physician workflows, reduce repetitive tasks, and enable providers to spend more of their time with patients.

One of the significant drivers of continued investment in digital health is the estimated 48% annual increase in patient data.  It is expected that patient data will reach 2,314 exabytes by 2020.  Physicians know there is endless data floating inside health systems from a myriad of disparate sources.  However,  how to access it at the right time and in the proper format has been a source of frustration.  A physician would have to work over 20+ hours per day to deliver all the nationally recommended care to an average patient panel, so asking them to search, collect, and interpret all this data as well is nothing short of absurd. 

Cue innovative solutions from startups.  Technologies that aggregate data and present it in an actionable format have emerged over the past few years.  However, for every piece of technology that takes work off the physician’s plate, a new one arrives that piles work back on.  With mHealth and patient-entered data apps erupting at a rapid pace, physicians can barely keep up with all the inputs being thrown at them.

The innovation frenzy timeline

As we review the innovation frenzy, the early wave of physician workflow solutions lived outside of the EHR.  These applications often required duplicate data entry, and although they measurably reduced time spent on tedious tasks, they were met with lackluster physician adoption.  At that time physicians were still grappling with the EHR and learning how to incorporate its workflow-disruptive requirements into their daily practice.  So, asking them to click into yet another application was understandably met with much resistance.

A shift in the digital health innovation space to create tools that deeply integrated with the EHR ensued .  The holy grail became technologies that worked seamlessly within the EHR with little to no disruption in documentation and order-entry workflows.  A noble intent, but the unexpected curveball was the enormous challenges that these young companies faced when attempting to integrate.  From archaic technology to uncooperative vendors with little desire to work with third-party apps, many of these new solutions were blocked before they could get a fair start.  Since those early days, most of the EHR vendors have improved their systems and/or their culture to remove these barriers, and startups can more easily integrate their solutions into the EHR systems.

Where do we go from here?

To advance the physician experience component of the Quadruple AIM, innovation needs to innovate.  Startups, entrepreneurs, and other stakeholders need to think outside the box.  We’ve come full circle.  From solutions that were rejected by physicians for requiring action outside of the EHR to deeply integrated solutions that are blocked by resource-strapped health system IT teams, it seems that healthcare technology must now figure out a plan “C.” 

 More and more providers want quick, real-time access to patient data beyond the EHR.  They want the data delivered in a non-intrusive yet actionable way.  They want this information to be customized for the care setting and patient acuity.  Moreover, they don’t want to click or open any other pieces of technology to get it.  Does that sound like wanting your cake and eating it too?  You bet it does.  Does it seem reasonable?  Absolutely.  Can it be done?  It already is…