In a prior post, I defined "meaningful use" of health IT (HIT) as "using HIT to increase care value (effectiveness and efficiency) by providing ever-better patient-centered cognitive support."
In this post, I do three things:
Defining Patient Patient-Centered Cognitive Support
As discussed in a recent report by the National Research Council of the National Academies, PCCS is a computerized process that improves decision making by fostering profound understanding through use of a "virtual patient" model.
According to their definition, the PCCS process employs a computerized model of a "virtual patient" that reflects (i.e., is an "abstraction of") an actual patient. An HIT tool would use this virtual patient to guide the selection and analysis of information that is:
In other words, the virtual patient used in the PCCS process is a computer program with advanced computational algorithms (mathematical and logical operations/steps). The algorithms "…incorporate physics (such as mechanical and electrical properties of tissue) and biology (from physiological to biochemical information) into a platform so that responses to varied stimuli (biological, chemical, physical, and…psychological) can be predicted and results viewed" [Ref: Oak Ridge National Laboratory ]. And HIT tool implementing the PCCS process takes "…observations of an individual patient and relates them to a vast dataset of observations of others with similar symptoms and known conditions. By processing all this information, the model can simulate the likely reaction of the individual patient to possible treatments or interventions. Such tools will not only improve the quality of treatment offered to patients who are already ill or injured, but could also be used in preventive medicine, to predict occurrence or worsening of specific diseases in people at risk, for example through family history [Ref: Europe's Information Society Portal ]. These simulations and predictions are used to support decisions by identifying the treatment and preventive approaches most beneficial to the virtual patient model, which would then be most likely to benefit the actual patient upon which the virtual model is based.
The HIT-PCCS Gap
Unfortunately, today's mainstream HIT systems do not employ the PCCS process. This, according to same National Research Council report, is a most serious HIT gap. The reason is that PCCS-enables HIT tools are essential for helping clinicians to understand their patients' problems and needs without having to:
Since they do not use the PCCS process, mainstream HIT tools do not:
Decision-making thus suffers as a consequence.
Eliminating the HIT-PCCS gap would enhance understanding and promote better shared decision-making about treatment, prevention, health promotion, and self-maintenance (see this link and this link ). Because both clinicians and patients would be better informed through the PCCS process, the decisions they make would be more likely result in better outcomes (higher quality and safety) at lower cost. This would translate into increased care value (effectiveness and efficiency). In other words, using HIT tools that implement the PCCS process would help realize important benefits to individuals and society. These benefits include achieving the goals of both the Federal HIT Strategic Plan and the Institutes for Healthcare Improvement's "Triple Aim."
Federal HIT Strategic Plan Goals
PCCS-enabled HIT would help achieve the goals of the Federal government's HIT strategy. According to the Office of the National Coordinator for Health Information Technology, the American Recovery and Reinvestment Act (ARRA) Implementation Plan:
Institutes for Healthcare Improvement's "Triple Aim"
PCCS-enabled HIT also help achieve the goals of the Institute for Healthcare Improvement (IHI) recently proposed healthcare improvement design—called the Triple Aim—which has these three critical objectives:
It is essential, therefore, that utilization of the PCCS process be included in the definition of meaningful use of HIT since sustainable healthcare reform benefits cannot be achieved without it!
PCCS and Meaningful Use of HIT
Based on the discussion to his point, it is reasonable to conclude that HIT tools are used meaningfully if they employ the PCCS process in order to:
The following section discusses how PCCS provides superior decision support.
PCCS and Decision Support
A key question concerning PCCS and decision support is: What HIT tools provide decision support and is this decision support based on the PCCS process? To answer this question, let's examine two classes of HIT tools that offering decision support: electronic health records (EHRs) and clinical decision support (CDS) systems.
Electronic Health Records
One type of HIT tool providing some decision support is the EHR (and its electronic medical record counterpart ). According to the Concise Guide to CCHIT Certification Criteria, certified EHRs deliver the following decision support capabilities (note that I combined ambulatory and inpatient EHR decision support criteria in the following list):
This list of criteria defines EHR-based decision support as: (a) warnings and alerts about abnormal test results and vital signs, medication issues, duplicate orders, follow-ups, immunizations, and certain therapy substitutions; (b) reminders regarding care due dates; (c) assistance with selection of basic general guidelines in certain situations; (d) general patient education materials; and (e) basic information for hospital nursing staff.
Such EHR-based decision support can be helpful in certain ways. However, since the do not employ the PCCS process, conventional EHRs do not:
And as a result, they do not:
So, even when EHRs provide decision support, their failure to employ the PCCS process severely limits their value in improving healthcare quality and controlling costs. The same can be said, by the way, for personal health records (PHRs).
Today's EHRs (and PHRs), therefore, fall far short of what is needed for "meaningful use" because they do not employ the PCCS process.
Let us now examine another type of HIT tool providing decision support: Clinical decision support (CDS) systems
Clinical Decision Support Systems
Clinical decision support (CDS) systems, not surprisingly, go well beyond the typical EHR in the area of decision support, and some may be add-ons to EHRs. These CDS systems offer:
Following are some examples of CDS systems:
Do such CDS systems employ the PCCS process? Well, things tend to get a bit blurry here. A CDS system does implement the PCCS process if it uses evolving virtual patient models to (a) automate data searching and sifting; (b) enable a deep and broad understanding of a patient's biopsychosocial health status; and (c) provide personalized decision support that accounts for patient preferences, qualities, and circumstances, as well as helps improve overall care value. Even if certain CDS systems do utilize the PCCS process, this HIT class is not commonly used in clinical practice or by patients, which only adds to HIT-PCCS gap.
Establishing Meaningful Use by Bridging the HIT-PCCS Gap
Bridging the HIT-PCCS gap means deploying mainstream HIT tools the implement the PCCS process. These tools would demonstrate a meaningful use of HIT, as discussed below.
Why Meaningful HIT Use Requires PCCS
The reason I'm making the PCCS process a requirement of meaningful HIT use is because it fosters profound understanding, supports evidence-based decisions, and promotes ever-greater care value by helping to answer questions such as:
Unless questions such as these can be answered validly and reliably, there is little chance that HIT decision-support will increase care value and realize sustained improvements in care effectiveness and efficiency.
This is why bridging the HIT-PCCS gap is essential to the meaningful use of HIT.
How HIT Tools can Provide PCCS
Creating and evolving innovative HIT tools that provide PCCS can be a daunting challenge. Accomplishing this goal would require innovative PCCS-enabled HIT tools that:
Managing complete personal health information (PHI)
Innovative HIT systems that employ PCCS should securely manage (obtain, analyze, and present) complete biopsychosocial PHI over people's entire lifetimes, and it should be relevant to both "sick-care" and "well-care." This information should provide a detailed of picture the whole person, both mind and body, because is crucial for the delivery of high value healthcare. In addition, these tools should enable PHI exchange wherever and whenever it is needed, and protect it via HIPAA-compliant security and " granular level" privacy methods.
Developing and using virtual patient models
It is important that these virtual patient models present decision-support information that is relevant to the specific patient (a) in the context of the current situation, and (b) in relation to the whole patient and his or her predispositions. Following are examples of what the models should do.
The virtual patient models should obtain comprehensive PHI from any data streams, manual inputs, biometric sensors, and data stores (databases, files, etc.). In addition to patient status and health history, this information should encompass clinical process data, as well as results tracking, which includes outcomes data, guideline compliance rates, and the reasons for variance (departures) from the guideline recommendations.
The virtual patient models should use computational algorithms that analyze the data obtained in order to identify important patterns (e.g., trends, associations, clusters, and differences) useful for making predictions, linking diagnosis to cost-effective treatments, conducting health-related surveillance (biosurveillance and post-market drug & medical device surveillance), etc. And test the data for statistical relevance to determine which information provides reasonable explanations. The results of such analyses would help determine, for example:
The virtual patient models should also provide feedback (including suggestions and reminders) and guidance (e.g., diagnostic aids and evidence-based guidelines) presented in personalized views that facilitate decision making, care coordination, and competent care delivery. This would help:
These models would, therefore, provide PCCS through useful personalized information that increases the likelihood of positive outcomes.
Supporting collaboration in loosely-coupled professional and social networks
Loosely-coupled professional and social networks (as opposed to technical networks) consist of people from multiple locations—who have different roles, responsibilities and experiences—who collaborate to make decisions beyond the knowledge or skills of any individual. These loosely-coupled networks would enable clinicians, researchers, patients, and informal caregivers to pool their wide diversities of knowledge, ideas, and points of view, thereby providing a larger collection of intellectual resource and offering access to a greater variety of non-redundant information and knowledge on which to base decisions.
For example, collaborating researchers and clinicians would foster the emergence of health science knowledge by analyzing, discussing, and interpreting care process and outcome data. This would promote the development virtual patient models by transforming this knowledge into evolving evidence-based guidelines aimed at the continuous improvement of care effectiveness and efficiency.
Another important thing they can do in these collaborative networks is share and "play seriously with" different virtual patient models. That is, they would compare models and test them for their ability to reflect reality accurately; they manipulate the models to represent different scenarios, such as "what if" scenarios about the probability of future occurrences; and they discuss the assumptions and results the models produce. When they find models that disagree or generate invalid results, they examine the fundamental assumptions built into the models, looking for logical flaws and inconsistencies and debating about the assumptions and practical value of the model. By challenging the model's assumptions, useful counterintuitive insights often emerge, innovative thought is sparked, new questions arise, and compelling and unexpected issues are discovered. This means that sharing and playing with models is an effective path to innovation and value creation.
As such, these loosely-coupled networks provide the greatest opportunities for emerging creative ways to develop, evolve, and use the virtual patient models that provide PCCS.
These loosely-coupled networks should be supported by a cyberinfrastructure that, as described by the National Science Foundation,"…combines computing, information management, networking and intelligent sensing systems into powerful tools for…collecting and analyzing large volumes of data, performing experiments with computer models and bringing together collaborators from many disciplines." [Ref: NSF ]. The cyberinfrastructure should be secure, economical, easy-to-use, and convenient.
Fitting the HIT tools into clinical workflows
PCCS-enabled HIT tools should assist clinicians in making decisions during their natural course of work, rather than requiring major adjustments of their workflows. This would increase the likelihood that clinicians will take advantage of that PCCS.
Any good definition of meaningful use of HIT ought to include the implementation of the PCCS process to drive ever-evolving clinical decision support. Since mainstream HIT tools to not employ the PCCS process, realizing such meaningful use will require real long-term commitment by diverse groups of collaborators in the development, use, and evolution of virtual patient models. If increasing healthcare value is truly our nation's goal, then there is no good alternative!
We ought to be cautious during this early stage not to define meaningful use simply in terms of what is currently being done by mainstream HIT (e.g., see the HIMSS definition developed by a major vendors' organization). Instead, the definition ought to refer to individual HIT tools, or the integration of multiple tools, which enable the implementation and evolution of PCCS. In other words, it's time for radical innovation!
The National Research Council's report calls for radical change this way:
This radical change requires radical HIT innovation, not passive reliance on the crop of conventional "me-too" commodities now crowding the market. Instead, we ought to be developing and promoting dramatically different types of software applications—a new generation of truly useful tools ("disruptive technologies/innovations")—that employ the kind of PCCS able to transform our healthcare system for the better.