Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions
Posted Jun 03 2009 4:52pm
On January 9, an very important report on the state of health care technology was released by the National Resource Council. Entitled "Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, this report is the product of some of the finest minds in computer science and health care informatics. Dr. William Stead from Vanderbilt was the Chair of this report. The effort involved numerous site visits, interviews, and literature reviews. It is ground-breaking work.
The pioneering work performed by the institutions visited (and the many other institutions discussed) demonstrates the many challenges ahead. Those responsible for this worked saw that even in the most advanced settings, information systems are not realizing their true potential.
Among the reports primary conclusions are (in this writer's words):
Our current approach - aimed at "information technology" rather than "informatics will not be sufficient to achieve the vision of 21st century health care. Indeed, merely automating the status quo and accelerating the current direction without more thought and change may be detrimental to the long-term well-being of our health care system.
Success will depend on our ability to place greater emphasis on cognitive support to providers, consumers, and policy makers. There is a greater need to focus on the decisions we all make and less on the transaction by-products of such decisions.
Much more will be written about this report, and it is only a start of a longer process. In addition, the report acknowledges up front that it does not address small practices, health care reimbursement and many other critical issues. But the take home point - let's focus on using the best we have available across various engineering and health disciplines and focus on the real health issues and not merely automate the myriad of transactions that are by-products of the way we think about these issues.
The report also provides principles for change. The first five principles are considered supportive of "evolutionary change" and the last four supportive of "radical change."
Focus on improvements in care - technology is secondary.
Seek incremental gain from incremental effort.
Record available data so that today’s biomedical knowledge can be used to interpret them to drive care, process improvement, and research.
Design for human and organizational factors so that social and institutional processes will not pose barriers to appropriately taking advantage of technology.
Support the cognitive functions of all caregivers, including health professionals,patients, and their families.
Architect information and work flow systems to accommodate disruptive change.
Archive data for subsequent re-interpretation, that is, in anticipation of future advances in biomedical knowledge that may change today’s interpretation of data and advances in computer science that may provide new ways extracting meaningful and useful knowledge from existing data stores.
Seek and develop technologies that identify and eliminate ineffective work processes.
Seek and develop technologies that clarify the context of data.
This is an extraordinary contribution well worth the read. Here are some of the thoughts I had when reading this report.
The report really emphasizes a few critical themes: think, don't automate; focus on the individual; avoid monolithic projects and think in terms of incremental progress. Only late in the report does the report hone in on empowering patients and their families but to empower individuals and improve care, we must blur e boundaries and expand the focus of care from traditional care delivery settings to the home. This is particularly important for chronic disease and to meet the varying needs of the elderly – progressive, intermittent frailty cannot be optimally addressed through our current model but can be addressed through the notions you present.
Although the Institute of Medicine is often cited as a basis for safety and learning health care systems and serves as a rationale for greater investment in the current generation of information technologies, most of these technologies fall far short of the IOM’s goals.
Why are clinicians reluctant to embrace IT? This report suggests some answers. Their reluctance may be the result of a rational skepticism of the acute impact of these systems in care delivery settings. If systems do not improve efficiency or quality at the point of care, they will be used only reluctantly. If systems are not used, expenditures towards these systems will be wasted effort.
Why is the public are people not embracing these ideas? Perhaps it is because many systems do not help us think more clearly as patients. Using report-speak, the phrase "cognitive functions" is often used. In the context of the individual or family facing illness, I think “cognitive functions” can be translated as: “help individuals and their family think more clearly about critical health care decisions and to make such decisions based on information they understand and guided by values they hold.”
Automation: The current state
The report rightfully claims that many current health care IT systems are monolithic and complex. Rather than enabling small effective changes, the many interdependencies result in an “all or nothing” approach which at times garners no improvement and at other times does harm.
Information exchange is not encouraged, so the health care needs and convenience of the individual are not met and care efficiency is not realized. Failures in these contexts are spectacular and have been described for over two decades. Paul Strassmann, among others, has been writing about this for years. Also Ed Yourdon, who's book "Death March" remains a classic in my mind.
IT "automates things" whether the processes automated are efficient or unecessarily complex
IT does not distinguish between efficient, informed care and care that is inadequate, unnecessarily complex, suboptimal, or possibly harmful.
Health care systems should ensure that clinicians and patients do what is best for care – even if doing what’s best requires changes in clinical behaviors and work flows. Doing what’s best changes as further evidence is gained. If systems are rigid practitioners and individuals cannot easily change their behaviors to accommodate new and better methods of care.
The limitations of technology
Technology often lulls us into complacency. Technology can allow action without thought. Often we keep busy filling out forms, modifying fonts, and formatting.....and we forget to think! If systems are not designed to encourage thinking and focus on typing, complex interfaces, and other mechanical aspects, they may distract thinking from the central issue – improving health. Systems should help individuals and caregivers think about better ways of providing care and not create an situation supporting mindless action.
We still don't know the best way to care for one another. We never will. Improvement is a way of life, not a path with a finite end. Systems should support discovery of better methods for treatment. This is done by “mining” connected bodies of data to enable better decision-making. Information on the care of individuals can be aggregated in ways that maintain privacy and confidentiality.
On the near-term, the report suggests that we focus on care improvements for the individual across a growing range of settings from hospital to home
Although it acknowledge the importance of claims (“record available data” ) other forms of data are fare more meaningful to patients and clinicians than data created for administrative and payment systems. Left to the current momentum, our health care IT infrastructure trajectory may emphasize “data” derived primarily from claims because that’s the kind of data the current power structure in health care (plans, government) has. To me that’s like the drunk who dropped his keys one night in an alley but looks for them at the corner under the lamp post because there is better lighting.
On the long-term, it is important to note that the "disruption" in health care has already taken place in the social and economic sphere, and systems we invest in should be used to accommodate these new realities. There is no turning back
The only way out of this mess is to focus on the individual in the context of the present; to retain information about the individual and this context in this time in a way that allows society to improve its methods over time as needs and contexts change.
To do this, one must archive data in a way that allows for relevant re-interpretation – that means holding onto the context in which information was gathered and the intent of such systems.