Wednesday, February 24, 2010

Data Silos, Core Measures, Performance Metrics, Outcomes, and Evidence-Based Guidelines

There has been a great deal of discussion about the need to exchange patient health information securely across disparate data silos while protecting patient privacy. I agree that this is an essential ingredient for transforming healthcare and have offered a solution in prior posts. But that's only one part of the big picture. We must also focus on the need for (and failure to) funnel comprehensive clinical outcomes measures to researchers who translate them into evidence-based guidelines reflecting cost-effective care. Health IT tools, therefore, should be competent in obtaining these data, delivering them to researchers, and then presenting the resulting guidelines to patients and providers as a means to improve and reward high-value care.

Case in point: The vast majority of "performance metrics" I've seen are based on "process measures" that evaluate care quality based on what was done instead of the outcomes/results of care. Unless this situation changes, care value (cost-effectiveness) is not likely to improve much. I've written about this situation years ago at http://curinghealthcare.blogspot.com/2007/05/knowledge-standards-and-healthcare_12.html. And interestingly enough, a recent article at http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100219/NEWS/302199990/1029# discusses the tension surrounding the use of "core measures" by the Office of the National Coordinator for Health Information Technology (ONC) and how they want to put more emphasis on outcome measures over process measures.

Bottom line: Sharing patient data is important, but using those data to improve care value systematically is a process that is largely overlooked. Today. This is a serious problem that must be addressed seriously.

Sunday, February 14, 2010

What is the Most Sensible way to Diagnose, Treat and Prevent Health Problems?


What is the most sensible—i.e., the least costly and most effective—process by which to:

  • Diagnose a particular patient's health problems
  • Treat those problems in order to increase the likelihood of getting the best clinical outcomes (symptom alleviation, blood text normalization, disease elimination, etc.)
  • Help people help themselves (e.g., prevent illness, manage chronic conditions, and deal effectively with psychological distress).
In some situations, this is common knowledge because the problem and remedy are both obvious (e.g., filling a tooth cavity, putting a cast on a broken arm or ice on a sprained ankle, removing a wart, testing a growth for skin cancer, etc.). But in very many situations:
  • A set of symptoms reflect a multitude of possible underlying problems
  • Comorbidity (two or more health problems exist at the same time, especially in persons with chronic conditions) complicate matters greatly
  • There are conflicting (no clear-cut agreed-upon) or inadequate guidelines/protocols/approaches for testing and treating certain conditions (see this link)
  • A person's mental/psychological state is affecting one's physical health (e.g., emotional stress affecting one's immune system) and visa versa (e.g., certain diseases affect one's emotions, thinking and behavior)
  • Medication side-effects and drug-drug interactions may be causing certain symptoms)
  • There is a significant influence of genetic as well as environmental factors
  • …and so on.
The unaided human mind typically cannot make useful sense of this incredible complexity, which is why we have a serious knowledge gap in healthcare (see this link).

What's needed is much more focus on better coordinated research—using both controlled studies and lessons learned from the field in everyday clinical practice—along with much greater use of EHRs and PHRs coupled with advanced decision-support tools. The goal ought to be the development of ever-evolving evidence-based guidelines focused on cost-effectiveness that are presented along a timeline of workflows (do A then B then C…) and/or using validated rules/algorithms based on mathematics and logic, which clinicians use to augment their experience and education.

If the healthcare industry move forward steadfastly in this rational direction, and rewarded providers for delivering high-value care, we'd be transforming our healthcare system in one that truly works.

Wednesday, February 10, 2010

A Novel Way to Share Personal Health Information


Patient health data are stored in disparate silos—separate islands of information residing in often incompatible EMR/EHR and PHR databases controlled by different hospitals, clinics and public health agencies, as well different group and solo practices. The question is: What is the best way for this personal health information to be shared securely between the people who need it to provide quality care to individual patients, protect populations, and perform research leading to valid evidence-based guidelines?

There's actually a simple, inexpensive and secure way to exchange data between any PHRs, EHRs, EMRs and public health/research/biosurveillance databases. As I've discussed in previous posts, it requires a paradigm shift from...

  • Monolithic, centralized, pull, synchronous systems—an architecture that's good behind an organization's firewall
to...
  • Distributed federation of asynchronous pub/sub nodes that push data from publishing to subscribing nodes—an architecture that's good for the kind of loosely coupled P2P networks crossing organizational boundaries that comprise the NHIN (National Health Information Network).
The latter architecture uses a node-to-node transport method, which is similar to the way the telephone system works. It enables everyone everywhere to exchange data with little cost and complexity, even when bandwidth is low and Internet access is intermittent. It enables massive interoperability. With it, scalability is a non-issue. It provides composite reports containing information from many disparate sources. And it allows data views to be changed instantaneously (even when offline), which increases understanding by, for example:
  • Data slicing, dicing and drilling down (i.e., breaking a body of information down into smaller parts, examining it from different viewpoints and dividing an information area up into finer and finer layers)
  • Switching from lists and tables to graphs
  • Answering ad hoc "what if" questions
  • etc.
In order to implement the above solution, you would connect pub/sub node software to every application in a mesh node network. And you would enable each node to do whatever data translations and transformations are needed to assure the right data gets to the right place in the right format. Then transmit the data to subscribing nodes in PKI encrypted delimited text files (such as CSV) via FTP, e-mail attachments, MMS, or whatever protocol desired. Upon receipt, the subscribing nodes can import the data into their local databases and/or render the data locally using customized templates that can operate interactively offline.

I discuss this solution in detail at this at my company's LinkedIn group at http://www.linkedin.com/groups?home=&gid=2697006&trk=anet_ug_hm&goback=%2Eanh_2697006. You're welcomed to join.

Monday, February 08, 2010

Is President Obama to Blame?


I recently received an anti-Obama e-mail with a link to a video that blamed the President for our country's current and future problems. This faulty/irrational way of thinking is a gross distortion of reality because no individual is responsible for our problems, not Obama, not Bush…no one!

Instead, our problems stem from a malfunctioning political-economic system and a misdirected culture. At its very core, our society is built on a foundation of beliefs and values that promote much of the negative side of human nature. The consequence is a political-economic system that, for example:

  • Allows money from special interests to dictate the actions of Congress
  • Repeatedly fails to fix our severely broken and unsustainable healthcare system (see this link)
  • Has created an overly lop-sided wealth and power distribution—with the wealthiest 10 percent of Americans having a larger share (about 50%) of total income than ever before (reference)—made worse by a lack of fiscal rules and regulations required to constrain irresponsibility and greed
  • Has enabled certain banks to become "to big to fail"
  • Engages in wars we can't possibly win by force (including military engagements and the war on drugs)
  • Created an education system in which American students performed worse in science and math than many other industrialized countries (reference)
  • …and so on.
Bottom line is that American political-economic system just doesn't work well for the vast majority of our citizens.

What we ought to be doing to fix our problems is focusing sincerely on reforming our political-economic system into one that:
  • Forces widespread transparency
  • Aligns the ought-tos with the can-dos
  • Provides an environment where all individuals are enabled to develop their positive potential
  • Is driven by empathy and compassion (e.g., living by the "Golden Rule" ethics)
  • Stops equating personal value (the inherent "worth" of one's self/ego) with personal wealth and power over others
  • Takes a long-term, big-picture view
  • Isn't fearful of fundamental change
  • Inhibits individuals from going into politics who are focused primarily on their own personal gains (e.g., by minimizing the money-politics connection through better campaign contribution reform and limiting politicians upon leaving office from becoming well-paid lobbyists for corporations they've helped)
  • Embraces both science and spirituality. 
Also, see this link for a discussion of convergence of 3 core healthcare reform issues: American values, personal responsibility, and pragmatic solutions.

So, what's standing in the way of such reform?

I contend that the answer, in large part, comes from analyzing this quote by Howard Zinn in a recent Bill Moyer's interview (at this link): "Democracy doesn't come from the top. It comes from the bottom. Democracy is not what governments do. It's what people do… whenever the government has done anything to bring about change, it's done so only because it's been pushed and prodded by social movements, by ordinary people organizing." And this quote takes from one of Zinn's books: "If democracy were to be given any meaning, if it were to go beyond the limits of capitalism and nationalism, this would not come, if history were any guide, from the top. It would come through citizen's movements, educating, organizing, agitating, striking, boycotting, demonstrating, threatening those in power with disruption of the stability they needed."

So, if things are so bas for so many, why don't "we the people" demand meaningful (aka radical) change?

Well, it takes certain ways of thinking and a good deal of motivation for people to pull themselves out of despair. They must transform their life views from being overwhelmed with a sense of hopelessness and helplessness to feeling hopeful, capable and having a clear direction by which they can actualize/realize their potential. This is possible, but not easy.

On the one hand, we all have the inherent capacity to change the way we think about ourselves, others, our current life situation and our futures. We can gain new knowledge and skills. We have the ability to become inspired and to act in constructive ways that enable us to develop their minds and bodies, and to attain a better quality of life.

On the other hand, the negative influences of our culture tend to foster the negative side of human nature to become dominant, which inhibit such positive thinking, learning and action. These negative influences include such things as:
  • Poor education, an unsafe living environment, racial prejudice, generations of poverty, propaganda and "spin"
  • Normal human thinking limitations (e.g., short-sightedness, over-generalization, low frustration tolerance, poor attention span, wishful thinking, close-mindedness, gullibility, misdirected focus, ignorance, influence of negative emotions, etc.)
  • Corporations who hire lobbyists to get laws passed that benefit them—i.e., creating the rules in their favor by "tilting the playfield"—which is often at the expense/detriment of the general public
  • Cultural attitudes in which "money makes the man," "winning the game is what matters" and "buyer beware" trump attitudes such as "leading a virtuous life matters," "how you play the game is what's important" and "focus on giving the consumer high value." 
And instead of supporting a "give me more of the pie" philosophy (i.e., "I deserve to be given more by the government as entitlements"), our culture should be promoting a "create your own pie" philosophy by:
  • Making available quality "ingredients," e.g., access to good education/training, availability of jobs, decent and affordable healthcare, safe neighborhoods and realistic reason for hope.
  • Promoting acceptance that the best pie a person has the potential to create will not necessarily be as "tasty" as other people's pies. That is, helping people realize that it's OK for some individuals to gain greater material rewards and power than others, as long as it's acquired in a virtuous manner (i.e., through honesty, integrity, value-creation, etc.), and as long as everyone's essential needs are satisfied (e.g., good food, healthcare, education and protection). 
It's my hope that grass-roots movements around the country focused on positive change will become powerful enough to exert the force needed to counteract the political, economic and psychological pressures preventing meaningful systemic reform. This appears to be the only reasonable way to avoid the meltdown of American Democracy.

Thursday, February 04, 2010

Curing Healthcare named a top 50 blog to learn about healthcare IT

According to the ratings, the blogs selected are updated on a regular basis to deal with an ever-changing field and present "relevant information along with a good following and a well-written and easy-to-comprehend blog." For the other blogs on the list, see this link -- http://mastersinhealthcare.org/2010/top-50-healthcare-it-blogs/