Saturday, December 13, 2008

Health Information Technology: Past Predictions, Current Reality, and Future Potential - Part 3 of 3

In my past two posts, I discussed why health information technology's (HIT's) potential is not being realized, and why it has thus far failed to deliver strong return on investment. I now focus on describing what has to be done to change things around in 2009 and beyond.

What's Needed in 2009 and Beyond

Making the most out of HIT is a key component of any effective healthcare reform strategy. HIT's potential to reduce costs and improving quality can be achieved if we:

  • Increase the benefits to providers for adopting and using HIT, including offering them serious financial incentives
  • Deal with the daunting issue of data and technology standards
  • Follow a well-designed blueprint for building a comprehensive integrated software system.

Increasing Benefits and Incentives to Providers

Increasing financial benefits to providers would involve monetary incentives and additional income generation to those who use HIT. Such economic models may include:

  • Increasing funds available for grants to purchase HIT systems
  • Offering pay-for-use bonuses
  • Paying providers who (with their patients' permission) send de-identified patient data to authorized aggregators who then publish the data to researchers for a fee
  • Supplying low cost, user-friendly HIT tools
  • Paying providers a higher rate for delivering cost-effective (i.e., high-value) care.

No matter how it's done, providers who use HIT should gain financially, especially if they demonstrate the ability to control costs and render high quality care. This requires substantial reform in our current healthcare system, and there is reason to believe the new administration will support expanded HIT use [Reference].

Dealing with Standards through Innovation

HIT systems should be flexible enough to adapt to evolving standards quickly and easily. Unfortunately, this is not the case as evidenced by the debate over changing to ICD-10 diagnostic codes [Reference]. With most HIT systems in use today, accommodating new data standard is a very costly process. In fact, even more detailed standards are being offered, such as the ABC codes, which supports a more precise and comprehensive documentation of patient encounters and a common language for comparing approaches to care [Reference].

In addition, when it comes to technology standards, we ought not reject new creative approaches with the potential to lower costs and speed information exchange. One such innovative model, offered by National Health Data Systems, is to use a node-to-node architecture with universal translation, which manages information transfer between computers in an asynchronous manner via a publisher-subscriber process [1]. The benefits of this method include its ability to:

  • Adjust to evolving data and technology standards quickly and inexpensively.
  • Save time, money and resources by minimizing data transmission and storage costs, while consuming minimal bandwidth.
  • Have minimal impact on existing IT systems and networks, so current operations can continue without disruption.
  • Reduce complexity and hassle by requiring no VPN configuration, avoiding firewall issues, and needing little if any IT support.
  • Tailor reports to end-users' needs by supporting both report compositing whereby different reports can be combined into an integrated report of the "big picture," and report fragmenting whereby components of a single report can be divided into multiple smaller ones.
  • Personalize instructional materials to end-users' particular needs by enabling competency-based and just-in-time eLearning, whereby the curriculum content delivered to an individual is determined by the person's current level of knowledge and/or particular knowledge needs.
  • Allow people to obtain, compute, distribute and present information asynchronously using local resources and only brief, occasional network connectivity, which reduces demands central servers, speeds reporting, increases mobility/portability, and enhances network resiliency (i.e., the network keeps working even when individual nodes are disrupted, which is unlike central sever disruption that brings its entire network down).
  • Enable loosely connected networks of individuals to share diverse experiences, data sources, information, knowledge, expertise, perspectives, ideas, and insights, which increase innovation and more effective decision-making.

Following a Comprehensive HIT Blueprint

In addition to offering provider incentives and dealing more effectively and creatively with standards, realizing HIT's potential requires that we see the big picture and follow a comprehensive blueprint. This all-encompassing model should define how a wide range of HIT tools work together (interoperate) in order to promote safe, effective, affordable sick-care, well-care, and public protection by:

  • Delivering the right information, at the right time, to the right person/people, and presented in a way that promotes accurate risk assessment, diagnoses, treatment decisions, and coordinated care
  • Supporting processes that advance the continuous evolution and use of evidence-based guidelines for both well-care (prevention and self-maintenance) and sick-care (conventional allopathic treatments and complementary and alternative approaches)
  • Assisting first responders and trauma center staff in a wide-spread emergency (e.g., bioterrorism, epidemic)
  • Providing ongoing biosurveillance and post-market drug and device surveillance [Reference].

Accomplishing this requires low cost, flexible, efficient, interoperable software systems that can accommodate any current and future data and operational standards, support decisions, build profound knowledge [Reference], and protect populations. In addition, they must be highly-secure, economical, easy-to-use, and always available. The HIT blueprint should, therefore, describe how a wide range of software systems would work conjointly to help:

  • Collect and integrate a lifetime of biomedical and psychological information in order to generate a detailed picture the whole person, both mind and body [Reference]
  • Manage the fluid exchange of the health information wherever and whenever it is needed, and present that information in ways tailored to each person's authorization and requirements
  • Providers make valid diagnostic decisions, as well as helping consumers understand their diagnoses and risks
  • Providers make valid, evidence-based preventive and treatment determinations, as well as helping consumers understand their options and manage their health wisely and responsibly
  • Providers in of all types (including primary care physicians, specialists, and wellness coaches) deliver appropriate care cost-effectively through efficient, safe and effective procedures, without under-testing, over-testing, under-treating, or over-treating their patients
  • Coordinate care across the entire healthcare continuum when multiple providers work with the same patient
  • Collaborative networks of providers, researchers, and other knowledge workers to analyze, discuss, and interpret care process and outcomes data, and to build evolving evidence-based diagnostic and practice guidelines for continuous improvement of care quality
  • First responders and trauma center staff to respond quickly and competently to crises affecting public health and safety
  • Employers (and other purchasers of health insurance) and health plans to get information they need to support their decisions, while protecting the privacy of individual consumer health information
  • Providers manage resources, including staff, medications, supplies, facilities, etc.
  • Speed workflows by streamlining tasks, such as scheduling, ordering, data entry, and generating forms and reports
  • Perform continuous biosurveillance and crisis management functions to help public health agencies handle emergencies, as well as post-market drug and medical device surveillance to identify dangerous medications and equipment
  • Support communications and discussions among loosely connected groups of individuals.

In addition, the blueprint should focus on the use of computerized decision support (CDS) tools, which offer guidance based on evidence-based guidelines. To be truly useful, the CDS software systems should:

  • Be speedy. When a clinical decision support system is slow, for whatever the reason, user satisfaction declines markedly. Taking more than a second or two to move from one screen to another is unacceptable to most clinicians.
  • Anticipate needs and deliver guidance in real time. The information providers need not only has to be available, but the CDS software should anticipate what is needed and deliver that information when it is needed. An example is recommending that a clinician physician change drug dosage or use different procedures based on a patient's condition. Consumers should also have access to CDS tools designed for nonprofessionals.
  • Fit into workflows. Providers are more likely to use guidelines when the information is presented during their natural course of work. Presenting a guideline involving medication as the physician is placing an order exemplifies this process.
  • Be designed through end user feedback. Developers should do substantial usability testing to obtain user feedback and guidance in order to make sure the CDS software is easy to operate, effectively alerts the user when their immediate attention is necessary, has screens and controls that are not confusing, etc.
  • Be flexible and complete. The system should enable providers to override suggestions and reminders, avoid redundancies, and offer alternatives when available.
  • Use one screen. Having a guideline fit on a single screen works best.
  • Minimize requests for additional information. That is, it should not require an individual to input more data than is necessary.
  • Evaluate outcomes. They should give researchers information they need to determine how effective a guideline is, so they can evolve the guideline accordingly.
  • Evaluate compliance and variance. They should determine the rate of compliance to a guideline and the reasons for variance (departures) from the recommended procedures, so the guidelines can be adjusted accordingly.
  • Be patient specific. The system should "provide access to information relevant to the specific patient in the context of the current situation and in relation to the whole patient and his or her predispositions. … Once the information is collected, refined, and distilled, an intelligent engine can sift through the aggregate to identify patterns and test for statistical relevance. The intelligent engine will compare the specific attributes of the patient (gender, age, family history, conditions, vital signs, etc.) to find success factors common with the aggregate pool of similar patients. The power of pattern recognition over the aggregate, but applied to the specific patient, yields personalized medicine. Personalized information is more likely to result in positive outcomes and to stimulate a positive change in the patient's behavior" [Reference].

The HIT blueprint should also include new, innovative technologies, such as:

  • Next-generation personal health records. One such example is our Personal Health Profiler™, which helps improve people's lives through self-exploration and knowledge building. This knowledge is built on a strong foundation of information that includes extensive actionable information related to psychological (cognitive, behavioral, and emotional) and social factors affecting one's wellbeing and overall quality of life, as well as biomedical information. It provides an innovative model—a novel framework—by which all healthcare consumers, providers, researchers, educators, and health information technology vendors can collaborate to develop ever-better tools for obtaining, organizing, and presenting health-related information. And its software modules are designed to make it easy and inexpensive to evolve continually by incorporating new information from many different sources, expanding their functionality in response to user feedback, and working in conjunction with third-party software products [2].
  • Order management systems. One example is our patent-pending Care Order Management System™ (COMS™), which combines clinical pathways functions with alerting and resource management functions. The result is a multifaceted software tool that promotes care quality by (a) helping establish and monitor plan of care implementation and alerting clinicians when orders are not carried out in a timely manner, thereby enabling adjustments to be made in the care plan to avoid adverse events and (b) enabling the efficient allocation of time and hospital resources—including staff, facility and space—by helping assure plans of care are carried out as ordered with minimal disruption. It tracks each procedure for every patient, computes resource requirements against current capacities, and provides staff real-time information needed to accommodate all plan of care orders in a timely manner. And when it determines that care is not being delivered according to the preferred practice guidelines—thereby putting a patient at risk—it triggers a process by which clinicians working with the patient are notified in a timely manner about the situation, and given the information they need to rectify the problem [3].
  • Emergency response systems. One such system is our Agent 9-1-1™ application, which combines the COMS™ application discussed above with patent-pending first responder software tools designed by one of our partners. In addition to helping trauma centers/hospitals manage care delivery and resources as through COMS™, it is designed to (a) deliver real-time decision support for rescue and transport of victims, (b) facilitates coordination of emergency command and control, and (c) provides a survivable communication network [4].

Unless our healthcare system adopts a comprehensive HIT blueprint that embraces creative innovation (similar the one outlined above), we will continue to build and deploy software systems that:

  • Fail to address the big picture
  • Rely solely on conventional commodities, rather than incorporating revolutionary, paradigm-shifting discoveries able to break through current day technological constraints.

Conclusion

HIT holds great promise; without it, meaningful healthcare is not possible and the value (cost-effectiveness) of care cannot improve significantly. Realizing HIT's potential, however, is no easy task. Nevertheless, it is achievable and a much brighter future awaits us all by beginning to:

  • Break through the economic barriers that are preventing widespread adoption of HIT through income generating opportunities for providers and consumers, as well as incentives for HIT use
  • Employ software systems that minimize the cost, complexity, and limitations of using data and technology standards
  • Use a comprehensive HIT blueprint that addresses the big picture by embracing true innovation and enabling all types of software systems to work conjointly for the benefit of all stakeholders.

Notes:

[1] For full disclosure, the following link includes a discussion of a patented technology I invented, which is being offered by my company -- http://cpsplit.typepad.com/

[2] For full disclosure, the following link includes a discussion of a proprietary technology I developed, which is being offered by my company -- http://curinghealthcare.blogspot.com/2008/04/personal-health-profiler-part-1.html

[3] For full disclosure, the following link discusses of a patent-pending technology I developed, which is being offered by my company -- http://www.nhds.com/coms_agent911.html

[4] For full disclosure, the following link discusses a patent-pending technology from my company and a partner -- http://www.nhds.com/coms_agent911.html

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