Synergy in Health Care and Technology

syn·er·gy

  

noun, plural syn·er·gies.

1.

the interaction of elements that when combined produce a total effect that is greater than the sum of the individual elements,contributions, etc.; synergism.

2.

Physiology, Medicine/Medical . the cooperative action of two or more muscles, nerves, or the like.

3.

Biochemistry, Pharmacology . the cooperative action of two or more stimuli or drugs.

Synergy is often listed as one of the most hated words in the corporate world. However, achieving synergy between clinicians and health care technology is a crucial element in achieving return on investment.

I have rarely been in discussions, meetings, or presentations where people are discussing how clinicians and technology are going to work together to produce the best outcomes. Most commonly, the discussion is centered on how we are going to tweak the technology to suit the clinicians... or motivate the clinicians to use the existing technology. Sometimes, the impact on the patient is part of the discussion, but rarely- if ever- is the benefit to the institution included. The content of these discussions are exactly why most institutions have not seen the return on investment that they expected from their health care technology.

Achieving synergy between clinicians and technology is absolutely necessary. Here's why. Clinicians are good at being clinicians: ambiguity and the unknown are acceptable and expected parts of their decision making. Computers, on the other hand, are good at being computers: they excel at making consistent and accurate decisions when provided with a full set of data. Most health care delivery involves decision making on both ends of this spectrum. When computers provide consistent and accurate information to clinicians  they are freed to make better decisions about the unknown. This facilitates optimal patient care, which of course benefits not only patients but creates value for institutions.

For anyone who has sat in a meeting like I described above, creating this needed synergy between clinicians technology may seem unlikely or even unattainable. The good news is that it is completely possible.

When I was involved in the project to decrease venous thromboembolism (VTE), it was clear to the team that interactions between clinicians and the EHR were synergistic. Recent research into the clinical decisions support tools we developed has actually quantified the effect of the synergy between providers and the EHR. While a computer-based algorithm could have been used to create reminders for clinicians about VTE prophylaxis, it would have only been 70% accurate in the population studied. However, without clinical decision support, providers were under-prophylaxing patients. By combining provider-based risk assessment with CDS to facilitate ordering prophylaxis, a greater than 50% reduction in nosocomial VTE was achieved. The synergy between clinicians and technology clearly improved care and outcomes for patients while also providing value to the institution by reducing never events.

Despite the sometimes negative connotations of the term "synergy," it needs to be on the agenda for any meeting discussing how clinicians and technology will work together to create the best outcomes.

Prioritizing End Users

Via tedytan on Flickr

Implementing an integrated electronic health record invariably results in competing priorities and competing end users. I've written before that I believe patients are the most important end user. However, that still leaves clinicians, technicians, support and ancillary staff- and the often-ignored institution- competing for high ranking in decision making and resource allocation.

In order to assist in decision making and set system-wide strategy, I utilize a three-tiered approach to ranking these needs. Growing up with a strong Star Trek influence, I've come to agree with the Vulcan notion that "the good of the many outweighs the good of the few."

With this belief in mind, patients, as a group, represent the top tier of importance. This means that with every decision that we make, we are asking "is this what is best for our patients?" If the answer is no, than another path must be chosen.

The second tier is the institution. The reasoning is two-fold.

Via puuikibeach on Flickr

First, the patients are best served through the success of high-quality institutions. The era of the individual physician providing comprehensive care is coming to a close in the US; it's simply too difficult for a single physician to organize and orchestrate the multiple facets of a patient's care. Although many are nostalgic for the days when a doctor made house calls with his stethoscope and bag, modern health care requires advanced diagnostics, multiple providers, nurse coordination, complex billing and an increasing technology.

Second, the institution exists as the governing body of the multiple individuals involved in delivering patient care. A successful institution will create an environment where conflicts are resolved and effective collaboration for the benefit of the patients is possible. The institution can arbitrate the wants and desires of individuals and groups of individuals to meet the ultimate goal of serving the patient.

Via janwillemsen on Flickr

The third tier are the individuals that are employed by or contracted by the institution. Many have tried to rank the importance of individuals and groups within this tier, suggesting that the desires of clinicians should receive greater weight in decision making than support and ancillary staff. However, in order to best meet the needs of the patients, the needs of these individuals must remain balanced. For instance, it does not serve the patient to purchase the fancy equipment requested by clinicians if it cannot be adequately disinfected by environmental services. Ultimately, the collective actions of every individual in the institution determine the quality of care that patients receive.

In order to realize the potential return on investment from integrated electronic health records, this tiered model must be embedded as a core value of healthcare institutions. By focusing efforts on benefiting patients, we will learn to use EHRs in ways that improve care and decrease cost, resulting in benefits for institutions and individuals.

What is #GoLiveGetCKM?

Doctor, Patient, and EHR. Source

Going live with 20+ applications at 5 hospitals and 95 clinics is a big deal. But a fully integrated electronic health record isn’t the end game.

#GoLiveGetCKM is about keeping the patient in the forefront of our minds during the intensity and mayhem of a big-bang go-live.

#GoLiveGetCKM is what happens when we leverage our EHR in every way possible to benefit our patients through research, practice-based evidence, improved efficiency, improved quality and decreased cost.

#GoLiveGetCKM is not about getting the system working, it’s about working the system.

Follow me on Twitter and follow #GoLiveGetCKM to see where we are headed!

Featured Post at Health Data Management Magazine

“Know the enemy and know yourself, and your victory will never be endangered; know the weather and know the ground, and your victory will then be complete.”

 Sun Tzu 500 B.C.

Twenty-five hundred years ago, Sun Tzu asserted that with sufficient knowledge about yourself, your opponent and the environment, your victory would be assured. In our battles against rising health care costs and medical errors, this wisdom has been lost...

Read more over at Health Data Management Magazine. 

PapPap, the Talking Scale, and Readmissions

My PapPap and my son. October, 2010

Geisinger Health Plan recently reported that the use of interactive voice response and telemonitoring technologies facilitated a 44% reduction in hospital readmissions for patients with congestive heart failure, diabetes, and hypertension. This reduction was demonstrated in a clinical trial studying the technologies above versus the standard post-hospitalization follow-up. My PapPap happened to be a participant in the pilot group that led to this study. 

Upon discharge from the hospital, my PapPap was given a "talking scale" and instructed to plug it into the power socket and phone line (the pilot group was not wireless.) Each morning, he was to stand on it and have his weight measured. Each morning, the scale would capture his weight and ask him a series of standard questions about how he was feeling.

This led to a great deal of cursing.

Being the man he is, my grandfather attempted to have a conversation with the scale. He wasn't trying to be difficult... he was just being himself. Let me replay a typical exchange between my PapPap and the scale:

Scale: Are you short of breath?
PapPap: Naw, my breathing's fine.
Scale: Are you short of breath?
PapPap: I already told you my breathing's okay.
Scale: Are you short of breath?
PapPap: Bernice! This damn thing's not working!
Scale: Are you short of breath?
PapPap: Bernice! Call Elaine and tell her this idiot scale's not working again!
Scale: Are you short of breath?
PapPap: No! Now, how many times do I have to tell you?
Scale: Okay. Do you have any swelling?

This type of exchange happened fairly routinely until we explained to him that the scale only wanted yes and no answers. After several days, my PapPap and the scale came to an understanding. One day, his weight and responses were outside of the acceptable standards and he received a call from his nurse. He was instructed to make some changes to his medications.

This type of early and personalized response kept him and patients like him from needing to return to the hospital. Yet, it wasn't the scale that kept him out of the hospital. It was the way Geisinger Health Plan managed the knowledge about his condition.

Through the use of the talking scale, GHP collected standardized data at regular intervals to create information about PapPap's clinical course. That information was combined with algorithms to create knowledge about his clinical condition and generate clinical alerts that notified his providers about the change in his condition. These alerts represent actionable knowledge that allowed for early interventions to be performed and prevent further clinical decline in each patient.

While many are lauding the technologies used in this study, it was not the the Bluetooth, the interactive voice recognition software nor the talking scale that produced such dramatic improvements. It was the generation of individualized actionable knowledge for each participant that led to GHP's success and my PapPap's continued recovery.

Although, to hear him tell it, that damn idiot scale had nothing to do with it! 

Patients Need Actionable Knowledge

Meaningful use has defined the data that should be included in a clinical summary.  According to Stage I, the following demonstrates the minimum requirement necessary to qualify for this measure.

"Just the facts, ma'am." That about sums it up. This summary includes the required data and can easily be extracted from the EHR.

But it doesn't do much else. It certainly doesn't engage the patient, provide them with actionable knowledge or meet the spirit of the meaningful use measure.

However, with minimal provider data entry, well thought out templates and re-formatting with the goal of patient engagement, the clinical summary can be packed with actionable knowledge. That same visit could produce something like this:

Presenting patients with knowledge about their health is a key in engaging them as active participants in their care. As medical providers, we need to demand that EHR vendors provide us with tools that will meet this need.

Meaningful Use Stage II comment period opens next week. We need to provide feedback so that loopholes like the one above are eliminated. What good is meeting program requirements if we haven't met the needs of the patient?

Meaningful Use and CKM

Source

Meaningful Use: What Is It?

• By definition, meaningful use refers to the use of certified electronic health record technology to perform certain tasks.
• Meaningful Use Stage I is ultimately an outline for better and more affordable healthcare
• While not yet established, it is hoped that Stage II and III will complete the first chapters of better and more affordable healthcare
• Meaningful Use is an important infrastructure for improving healthcare
• Meaningful Use limits its focus to using technology

 Meaningful Use: What Isn't It?

• Meaningful Use is not a comprehensive plan to leverage technology for healthcare improvement
• Meaningful Use is not focused on the use of data
• Meaningful Use is not Clinical Knowledge Management

Meaningful Use and Clinical Knowledge Management

Meaningful Use is focused on the collection, storage, and reporting of data, not the creation of actionable knowledge. While MU creates outlines, paragraphs, and chapters in data collection, Clinical Knowledge Management creates volumes of knowledge to improve all aspects of healthcare. These volumes of knowledge are needed if we are ever going to bend the cost curve in the US healthcare system. 

MU needs to be built with this end in mind; if we don't take this opportunity to build the necessary infrastructure, we will not be able to generate the knowledge needed to make a sustainable US healthcare system. The conversations about MU need to expand beyond implementation dates, reimbursement, and vendor/physician concerns. We need to include discussions about which data needs to be captured to insure the generation of sufficient knowledge to allow optimal return from the investment in Meaningful Use.

Revealing Bias in Healthcare Decision Making

Source

I've recently been reading the Song of Ice and Fire series (Game of Thrones) by George R. R. Martin. While the plot is engaging and intriguing, one of the things I enjoy about the book is that it is written from the third person multiple perspective. Each chapter is limited to a specific character's perspective, but many characters get to tell the story. With this narrator point of view, the story develops with more layers and nuance than other perspectives. Each character's biases are revealed, and the reader is able to develop their own opinion of the events in the story.

Bringing the bias of each character to the surface through the third person multiple perspective deepens the understanding of the setting of the book. Similarly, bringing the bias to the surface in healthcare decision making helps us develop better knowledge and make better decisions. Just as each character in the novel is limited by what they can sense and feel, so each type of healthcare knowledge is limited by the constraints of its data.

These constraints make the exclusive use of any single type of healthcare knowledge unwise. We need to use multiple types of healthcare knowledge to better understand the current environment. For instance, in any single healthcare decision making process, knowledge can be garnered through:

• Institutional knowledge
• Quality knowledge
• Research knowledge
• Financial knowledge
• Operational knowledge
• Medical knowledge
• Direct Care knowledge
• Transactional knowledge
• Analytical knowledge

When we combine multiple types of healthcare knowledge we are able to develop a more layered and nuanced understanding of the challenge facing us and thus make better decisions and take more appropriate actions.

Better Questions, Better Answers, Better Solutions

Often, when we are struggling to make good decisions, the problem is not the quality of the data available… it is the quality of the question.  This is because the threshold for achieving actionable knowledge is dependent on the question being asked. The more simple and specific you make the question, the easier it is to gather enough information to reach the threshold for actionable knowledge. If the question being asked is too broad, the question itself may prevent the creation of actionable knowledge.

A perfect example of this in the medical field is the current discussion about salt intake. The main concern is the sodium component of salt. Diets high in sodium have been associated with increased rates of hypertension, which is clearly linked to an increased chance of heart attack and stroke. Because of these associations, there has been a public health campaign to advise adults in the US to reduce their salt intake. However, the campaign to reduce salt consumption has recently become controversial. This controversy stems from asking a question that is too broad to facilitate the creation of actionable knowledge. The question being asked is “What should we tell the US adult population about salt intake?”

A recent article in the Archives of Internal Medicine demonstrated a reduction in cardiovascular mortality associated with lower sodium diets. The study was statistically adjusted to be a representative sample of the US population. This article gives the appearance of creating sufficient actionable knowledge to tell the US population to eat less salt. However, two other recent studies create serious doubts about that conclusion. The first study, published in the New England Journal of Medicine, was also a study modeling the US and showed that the mortality benefit for a lower sodium diet had a significantly larger impact for blacks than for whites. The second article, published in the Journal of the American Medical Association, was a European study that only looked at a relatively young and healthy white cohort; this study demonstrated a large increase in mortality for the subjects with the lowest sodium diets.

These articles appear to disagree and there have been discussions about the methods of each study. No study is perfect and the conclusions from any of the three may be proven incorrect, but it is also possible that all three may be correct. It is possible that young and healthy whites in Europe may be harmed by a diet that restricts salt intake. Sodium is necessary for several biological functions. However, white, young, and healthy only represent a small group in a study that utilizing a sample representative of the adult US population. The potential harm to the white, young, and healthy cohort may be washed out by the benefits for other groups.

These studies create debate because the question being asked is too broad. If you believe that eating less salt will harm a cohort of people, it is unethical to tell them to do so. If you are then trying to take action based on the question “What should we tell the US adult population about salt intake?” you have quite a dilemma.

I suggest in these cases you don’t try to solve that dilemma with more data, information and knowledge. You solve it by changing the question. If some groups are helped by an action and others harmed, the question should not be “what advice do we give the whole population?” The question should be “how do I advise each cohort in the population?”

With regard to salt intake, we should stop asking “what should we tell the US adult population about salt intake?” and start asking "who in the US do we need to tell to eat less salt?"

CKM and Serenity

Clinical informatics and electronic health records are often offered as the path to high quality medical care and reduced adverse events. However, technology can only help deliver the best care medical knowledge can achieve. Frequently, even with the best implementation, technology can only get adverse events and complications of care to an irreducible minimum. After that new medical knowledge is needed. This is where CKM can be extremely important. Even when CKM doesn’t provide new knowledge for medical advancement, it can provide a clear indication if an irreducible minimum has been meet.

When considering this, I often think of the Serenity Prayer.

God grant me the serenity 
to accept the things I cannot change;
courage to change the things I can;
and wisdom to know the difference.

CKM can help provide the wisdom to know the difference. Well designed CKM can determine if patients received ideal care for specific disorders, i.e. early goal directed therapy for sepsis. If 100 patients all received perfect care and 20 died then there is nothing to change. However, if 100 patients received less than perfect care and 30 died, we need to have the courage to change the system.  

American Airlines and CKM

The other morning I was sitting in a meeting and a question was raised. That question was "do we really know that understanding our data better, and using tools such as data visualization, will really improve healthcare?"

Only in healthcare would this question still be asked in 2011.

Industries of all types have learned over the last 20 years the power of developing knowledge based on their actions and the actions of their customers. Many of these industries are not as complicated as healthcare. But I believe that the idea that healthcare is the most complex industry is erroneous; however, it's been my experience that this idea is deeply rooted in the culture of medicine. It seems to be felt that since there are so many uncontrollable factors such as patient complexity, patient compliance, variations in disease presentation, and the intricate web of payers and delivery systems, it is not possible to understand the "healthcare system" with data. I do not believe this is true, and in support of my position, I'd like to present a case from an industry that is at least as complex as the healthcare system: the airline industry.

Within the airline industry, the uncontrollable variable range from mechanical problems to passenger behavior to natural disasters to terrorist attacks... to the most unpredictable of all- the weather! Despite all of these variables, there are many examples of how the airline industry has transformed data into knowledge, improved service, and remained profitable.

Take, for example, the recent case study reported by American Airlines. American Airlines had identified fraud as a major cost to their business. However, they had no data warehouse technology or knowledge management plan for addressing fraud in their system. It was originally estimated that an effective data analytics system would save the company $150,000 per year. Using an "off-the-shelf" data warehouse solution, great gains were immediately seen, and ultimately saved the company $5 million over 5 years. The success was credited to the new system's ability to identify forms of fraud that the company never knew existed and giving the company the ability to make changes to eliminate those causes.

While it is true that we may be many decades away from being truly knowledgeable about how the US healthcare system works, it is also true that there are many technologies available today that, if utilized in healthcare, could have immediate and meaningful impact. Targeted solutions can quickly exceed expectations when we focus on creating new actionable knowledge with current technologies.

CKM and Spaghetti Sauce

One of the key components to clinical knowledge management is the discovery of actionable knowledge. The process of discovering knowledge is often more of an art than a science. A complex part of the art is asking the right question. The knowledge discovered and developed through data driven techniques such as data mining and statistical hypothesis testing are always framed by the questions being asked. Ask the wrong question, generate the wrong knowledge. Unfortunately, unless you know you are asking the wrong question you assume you are working with the right knowledge. 

Gains can be made when making decisions with the “wrong knowledge,” but they will be less than the gains made if decisions were made from the right knowledge. An excellent example of how knowledge is improved when you ask the right question is described by Malcolm Gladwell in his TED talk about the food industry and a spaghetti sauce breakthrough.

Gladwell describes how chunky spaghetti sauce revolutionized the food industry…  because companies stopped asking their research teams to find the perfect food and started to ask them to find the best food for a cluster of people. The right question was not “what is the perfect spaghetti sauce?”(or mustard or soda.) The right question was “which varieties of spaghetti sauce greatly appealed to large groups of people?” The result was more food options, happier customers and increased revenue.

Who is the End User?

It is generally accepted that information systems should be designed to benefit the end user. However, it is often unclear who the end user is. The answer to this question seems even more unclear in health information systems.


Thomas Goetz, executive editor or Wired and author of "The Decision Tree: Taking Control of Your Health in the New Era of Personalized Medicine" articulates a great argument that the end user of health information systems should be the patient.






I've held this same opinion for quite some time. Watching this TED talk causes me to think back to my studies of the Kimball Group's method of data warehouse implementation, outlined in their book, The Data Warehouse Lifestyle Toolkit. A large portion of this book was dedicated to end user identification and needs assessment. 


While there are many stakeholders in health care, and any one of them may be an end user for an individual application, the ultimate beneficiary of all health care information systems should be the patient. In the field of Clinical Knowledge Management, this means the focus must be maintained on ensuring that knowledge for improved decision making is made available not only to clinicians, but also to patients.