A Whole-Person Approach to Diabetes Health Education Part 2 of 4

In my last post, I presented an overview of the mind-body approach to diabetes health education. In this post I give a more in-depth examination of the psychological factors influencing blood glucose control, starting with the effects of emotional depression.

Psychology of Diabetes: How Mind Affects Health

Diabetes requires extreme changes to many people's lifestyles. They must change from a sedentary to health-conscious lifestyle. Instead of eating junk food and watching television, they have to begin eating healthy food, exercise regularly, monitor their blood sugar level multiple times a day, control their blood pressure and cholesterol, have regular eye and foot exams, stop smoking, and possibly take medications (which may include self-injection). Adopting these lifestyle changes and adhering to these self-management routines requires education and guidance, of course. Many diabetic individuals, however, need more than knowledge and instruction. The reason: Psychological obstacles interfere with their ability and willingness to make such dramatic lifestyle changes.
These psychological obstacles may include maladaptive (inappropriate, detrimental) attitudes, coping skills, and emotions. For example:

• Lack of self-confidence is enough to deter some people from even trying to change their lifestyle since they expect to fail.
• Just looking at a sugary snack can cause some people to worry about the life-threatening aspects of their disease, or feel depressed and angry that they must deprive themselves.
• Failure to keep up their exercise routine or eating poorly can also make them feel those same negative emotions. Unhealthy behavior can also make them feel guilty or ashamed for not doing what they should.

Unfortunately, instead of motivating them to control their diabetes, these attitudes and emotions can have the exact opposite effect; they may cause diabetic people to stop trying because they feel hopeless and helpless. Or equally harmful, they may deal with their painful feelings by ignoring their health through denial and self-deception. Following are some examples of the deleterious effects of these psychological obstacles on diabetic individuals.

Depression and Diabetes Management

Health Effects of Depression
Research shows that depression in diabetic people is associated with poorer diet and medication adherence, functional impairment, and higher health care costs.[1][2] This is often a vicious cycle. When the demands of diabetes care or complications of the disease lead to depression, a person feels overwhelmed, hopeless, helpless, and exhausted. These feelings, in turn, destroy one's motivation, which impairs self-management. Failure to manage one's diabetes results in greater health problems, which exacerbate the depression. And the cycle repeats.

Likewise, depressed people are unlikely to modify their behaviors to extend their lives because the prospect of living longer in chronic emotional pain shatters their willingness to change. Furthermore, depressed diabetic individuals may refuse to acknowledge that their illness can severely harm or kill them because the idea is too emotionally painful to accept. This means that the threat of serious complications or death is not a powerful motivator for some. In fact, the odds are nine to one that a person will fail to make substantial lifestyle changes, even if facing probable death!

Dealing with Depression
Fortunately, there are effective ways to help diabetic people overcome the psychological obstacle of depression. For example, compelling discoveries in the fields of cognitive science, linguistics and neuroscience are demonstrating the promise of "reframing" techniques. One useful reframing method helps depressed people develop a vision of "joy of living" rather than a "fear of dying," since joy can be a more powerful motivator than fear. Incorporating this kind of reframing approach into diabetes health education can promote positive changes in people's way of thinking, resulting in increased motivation to live more healthily.[3]

Diabetic people also need good coping strategies for dealing with depression (and other emotional disturbances). Some coping strategies attempt to reduce one's emotional distress by promoting adaptive (effective, useful) ways of thinking, feeling, and acting when trying to manage their illness (or other problems); other strategies, however, are maladaptive. Ten common strategies people use include five adaptive and five maladaptive coping methods.

The five positive, adaptive coping strategies help a person solve a problem or learn to accept it with minimal distress:

• Logical Analysis involves trying to understand what caused the health problem and different ways to handle it.
• Problem Solving involves developing specific plan of action to manage the problem, implementing it, learning from the results, and then modifying the plan and trying again if necessary.
• Social Support involves explaining the problem to other people and asking them for advice or help; this includes peer group support.
• Positive Reappraisal involves viewing the problem as helping the person change or grow in a good way, find new faith, or learn valuable lessons.
• Rational Acceptance involves accepting—without undue emotional distress and without self-defeating behaviors—that nothing can be done to cure one's illness; at the same time, it encourages the person to do what is necessary to prevent complications.
• The five negative, maladaptive coping strategies fail to resolve one's problems, do not enable healthy acceptance, and may even make the situation worse:
• Behavioral Distraction involves trying to feel better emotionally by doing enjoyable or interesting things, rather than dealing with the health problem proactively or coping with it through positive reappraisal and rational acceptance. While it may help reduce a person's emotional distress temporarily, this strategy is maladaptive because it will never improve the situation, does nothing to help one cope with it long-term, and can actually make matters worse through inaction. This strategy wastes precise time that could be better spent trying to understand and deal constructively with the problem.
• Cognitive Avoidance involves acting as if there is no problem, or trying not to think about the problem. As with behavioral distraction, the strategy may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
• Emotional Discharge involves expressing negative emotions by yelling or crying, taking it out on others, or avoiding certain situations. As with the previous two strategies, this one may help reduce one's upset temporarily, but it will never improve the situation and does nothing to help one cope with it long-term. In addition, this strategy may annoy other people who could have been helpful and push them away.
• Wishful Thinking involves hoping a miracle will somehow make things better, or that one's wishes or prayers would somehow be answered. This, too, may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
• Resignation happens when a person determines that nothing can be done to fix a problem, so he or she does nothing, while remaining in an emotionally distressed state of anxiety, depression (hopelessness and helpless), and/or anger. This, too, is obviously maladaptive.

It stands to reason, therefore, that helping depressed persons in diabetes health education programs deal with their depressions—through reframing, coping skill training [4], and other methods—will result in better outcomes (i.e., more effective control of blood glucose, blood pressure, etc.).
In my next post, I discuss how mental stress and personality factors affect diabetes management.

References:
[1] Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. 1: Arch Intern Med. 2000 Nov 27;160(21):3278-85. See http://www.ncbi.nlm.nih.gov/pubmed/11088090

Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, Blais MA, Meigs JB, Grant RW. Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. 1: Diabetes Care. 2007 Sep;30(9):2222-7. See this link

[2] Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001 Jun;24(6):1069-78. See this link

[3] Deutschman, A. Change or Die. 2005 May. See this link

[4] Grey, M. Coping and Diabetes. Diabetes Spectrum. 2000 13(3),167. See this link
Grey, M. & Berry, D. Coping skills training and problem solving in diabetes. Curr Diab Rep. 2004 Apr;4 (2):126-31

A Whole-Person Approach to Diabetes Health Education Part 1 of 4

In this series of posts, I focus on diabetes health education aimed at promoting effective self-management of this chronic condition. In particular, I discuss why a whole-person (mind-body) approach to diabetes health education is essential. After all, a good deal or research shows how glycemic (blood sugar) control in persons with diabetes may be significantly influenced by psychological factors.[1][2]

Overview: The Mind-Body Connection and Diabetes

Effective self-management of diabetes mellitus (DM) and other chronic illnesses is difficult for many individuals. Their problem stems from a powerful interaction between psychological and physiological factors. This mind-body connection is the bases for a whole-person approach to diabetes health education.

Physiological Perspective

From a physiological (body, biomedical) perspective, DM is a heterogeneous metabolic disorder characterized by hyperglycemia, a serious condition of elevated blood glucose (high blood sugar) level. Hyperglycemia is caused by defective insulin secretion, resistance to insulin action, or both.[3] The causes and treatment of hyperglycemia differ in the two types of diabetes.

Two Types of Diabetes

Type 1 diabetes is the consequence of an autoimmune-mediated destruction of pancreatic β-cells, which may be due to such things as genetics, poor diet (malnutrition), and environment (virus affecting pancreas). The result is insulin deficiency and requires insulin treatment for survival.

Type 2 diabetes, on the other hand, is typically characterized by insulin resistance, which means the body produces adequate insulin levels but cannot effectively utilize it; and in some cases, the body fails to produce sufficient insulin. This may be due to gene mutations and environmental factors, such as an inactive lifestyle or poor diet, which may act as a trigger for someone with such a genetic tendency, as well as by chronic stress and low birth weight (and associated fetal malnourishment). Treatment of Type 2 diabetes is aimed at reducing insulin resistance through diet, exercise and drug therapy, and, for some people, may eventually require regular insulin injections to keep their blood glucose levels in control.

Potential Medical Complications of Diabetes

There are many potential long-term complications of diabetes. They include loss of vision, renal failure, foot ulcers and amputation, as well as gastrointestinal, urinary, cardiovascular, and sexual problems. Effective glycemic control avoids or postpones these complications.

Psychological Perspective

From a psychological (mind, mental health) perspective, a diabetic person's knowledge, attitudes, and emotions are key. These mental functions and emotions interact to determine how well he or she is likely to manage the illness. That is, diabetic people who control their blood glucose effectively:

• Understand proper diet, exercise, medication, self-monitoring, etc.
  
• Use ongoing feedback to modify their behaviors
  
• Have healthy, rational attitudes (beliefs, thoughts, and perceptions)
  
• Maintain positive emotions
  
• Have a sense of competence and confidence (self-efficacy)
  
• Control their mental stress.

Having this knowledge, awareness, way of thinking, feelings, confidence, and coping ability gives people the proper focus and tools to successfully manage their condition. Being psychologically equipped in this manner makes them more likely to change their lifestyles in a positive way and adhere to their plans of care over the long-term. This is why a whole-person (mind-body) approach to diabetes health education is so important.

In my next post, I will offer an in-depth examination of these psychological factors.

References:
[1] Rose M, Fliege H, Hildebrandt M, Schirop T, Klapp BF. The network of psychological variables in patients with diabetes and their importance for quality of life and metabolic control. Diabetes Care. 2002 Jan;25(1):35-42. See http://care.diabetesjournals.org/cgi/content/full/25/1/35/F2
[2] Dharmalingam, M. Psychological distress and diabetes: Clinical and metabolic connections. International Journal of Diabetes in Developing Countries. 2005 25(4):92-97.
[3] Gavin III JR, Alberti KGMM, Davidson MB, DeFronzo RA, Drash A, Gabbe SG, Genuth S, Harris MI, Kahn R, Keen H, Knowler WC, Lebovitz H, Maclaren NK, Palmer JP, Raskin P, Rizza RA, Stem MP : Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care. 1997 20:1183-1197. See http://care.diabetesjournals.org/cgi/content/full/25/suppl_1/s5

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

Health Information Technology: Past Predictions, Current Reality, and Future Potential - Part 2 of 3

In my previous post, I discussed the great promise of health information technology (HIT), and explained why its actual economic and quality improvement benefits over the past five years have been disappointing. I will now examine several other reasons why HIT has not realized its potential: Low adoption rates, the double-edged sword of standards, and lack of a big picture blueprint.

Low Adoption Rates

Few providers have adopted HIT, and only a meager 2% of the healthcare industry's gross revenues is being spent on HIT. Although the adoption rate numbers can be confusing—since there are different rates for large organizations and small practices, by physician specialty [Reference];and since studies may combine EMRs, EHRs and computerized physician order entry systems (CPOEs) in different ways—the rate of HIT adoption is clearly low. Consider the following findings cited in the CBO report, which are from studies done between 2006-7:

• HIT was used in about 12% of physicians and 11% of hospitals
  
• 24% of office-based physicians used an EHR, with adoption rates of 16% for small offices and 39% for large ones
  
• 12.4% of nonfederal office-based physicians used a comprehensive HIT system
  
• 5% of hospitals used CPOE systems
  
• 11% of nonfederal hospitals had fully implemented EHRs, which were more likely in large urban or teaching hospitals.

More recently, a 2008 national survey by the New England Journal of Medicine found that electronic records were used in less than 9% of small offices (those with one to three doctors), which comprises nearly half of the country's medical practices [Reference]. And market growth for EMRs in the near future is predicted to be slow [Reference].

When it comes to personal health records (PHRs), a 2007 report by Forrester research indicated that only 7 percent of consumers have used an insurer-based PHR; the reason: "34% of respondents said they do not trust the security of computer programs and 29% said they do not believe there is a significant benefit to maintaining a PHR" [Reference]. In another study done that same year, nearly two-thirds of adults were not familiar with PHRs [Reference].

Barriers to HIT Adoption

According to the RAND study cited earlier, barriers to wider adoption of HIT include:

• High initial acquisition and implementation costs
  
• Slow and uncertain financial payoffs for providers
  
• Disruption of physician practices during implementation
  
• Payment systems give most savings insurers and patients, while providers bare most adoption and care improvement costs.

Here's what the CBO report said about the primary barrier to HIT adoption: "How well health IT lives up to its potential depends in part on how effectively financial incentives can be realigned to encourage the optimal use of the technology's capabilities."

Without adequate benefits to providers and a sufficient rate of adoption, HIT cannot realize its potential. To make matters worse, there's a third reason HIT is failing to realize its potential: The mixed blessing of data and technology standards.

Standards: A Double-Edge Sword

Standards are models, principles, policies, or rules that provide an agreed-upon framework for doing and understanding things. The two most important types of standards for HIT are data and technology standards [Reference].

Data standards describe how health data are to be categorized and defined. They include terminology, care measurement, and care process standards:

• Terminology standards include classifications and vocabularies that group together related terms so they can be more easily and consistently understood. Classifications arrange related terms for easy retrieval. Vocabularies use sets of specialized terms to facilitate communication by reducing ambiguity.
  
• Care measurement and process standards, on the other hand, focus on diagnosing health problems, selecting and delivering treatments, and evaluating care performance and value.

Whereas data standards focus on making information understandable and useful to humans, technology standards—and messaging format standards in particular—focus on enabling the exchange of data (i.e., "transactions") from computer-to-computer across individuals and healthcare systems.

While such standards are no doubt important, they are a double-edged sword because:

• Terminology standards are very difficult to agree on in healthcare since, for example, there are 126 ways to say "high blood pressure." And although setting an arbitrary standard for health-related terms is a way to foster widespread communications (e.g., by using the term "hypertension" to refer to all forms of high blood pressure), such standards force information loss due to "reduced semantic precision and nuance." Said another way, there are good reasons to have multiple ways of saying high blood pressure. For example, malignant hypertension refers to very high blood pressure with swelling of the optic nerve behind the eye, which is usually accompanied by other organ damage like heart failure, kidney failure, and hypertensive encephalopathy. Pregnancy-induced hypertension, on the other hand, is a pregnancy-induced form of high blood pressure (also called toxemia or preeclampsia). Referring to a patient's condition using only the standard term, "hypertension," while clearly conveying that the person has high blood pressure, looses these important details, which could very well affect treatment decisions and outcomes.

• When it comes to care measurement and process standards, it is difficult to achieve wide-ranging and meaningful quality standards for every healthcare discipline. And even if you do, the standards should evolve continuously, changing as necessary to accommodate new knowledge. On top of that, there is often considerable external pressure from powerful groups with a vested interest in influencing the selection of the standards. Furthermore, simply maintaining nation-wide data standards is a slow and costly process.

• In creating the technology messaging standards, the Healthcare Information Technology Standards Panel identified an initial set of 90 medical and technology standards, out of an original list of about 600, which included such things as how lab reports are to be exchanged electronically and entered into a patient's electronic record, as well as how past lab results are to be requested. More than 190 organizations-representing consumers, providers, government agencies, and standards development organizations-participating in the panel. Coming to a consensus was very difficult and fraught with politics involving intense negotiations and delicate compromises. And once such IT standards are set, software systems and databases must be designed to conform to those standards, even if there are more cost-effective alternatives [Reference].
  

So, the creation, maintenance, and use of HIT-related standards are additional sources of hassle and expense, which have been adversely affecting efforts to realize its potential.

Now here's a fourth reason for HIT's failure to achieve its potential: Lack of a big picture blueprint

No Big Picture Blueprint

Progress is being further stifled by the lack of comprehensive HIT blueprint. What is needed is a plan for designing a complete system, comprised of many different types of software tools, that enables the delivery of ever better and more affordable care by supporting collaborative knowledge-based efforts to increase positive quality, reduce costs, and protect populations.

Having examined why HIT's potential is not being realized, and discussed why has thus far failed to deliver strong ROI, my next post will focus on describing what has to be done to change things around in 2009 and beyond.

In my next post, I discuss what's needed in 2009 and beyond.