Practices for Comprehensive Health IT Systems

Following are practices for developing comprehensive health IT systems.

Something I realized early on is that such systems should be flexible enough to continually adapt to new healthcare knowledge and concepts; data models; value sets; data format, terminology and transport standards; use cases; workflows; and diverse user needs.

It should be able to accommodate the needs of PCPs and all clinical specialties, approaches and user roles, as well as patients, with highly useful and useable tools.

It should be able to work in centralized, distributed, point-to-point, and tightly- and loosely-coupled networks using client-server and standalone (desktop) tools.

It should be able to leverage cloud-based storage and computing (all flavors), as well as the local resources of untethered devices that may connect to the internet occasionally.

It should be able to work with third-party tools that provide additional relevant capabilities.

And if it provides decision support, it should focus on enabling knowledge-feedback loops among diverse groups of collaborators who build, share and refine models aimed at continually increasing the value of care patients receive through systematic process and outcomes research that cross organizational and geopolitical boundaries. These models should include ones that focus on the whole person (biomedical and psychosocial), social determinants of health (SDH), precision medicine, clinical workflows, population health, finances, and prevention (wellness care) as well as treatment and self-maintenance of chronic conditions.

Is the Biopsychosocial Approach a Scientific Model?

The biopsychosocial (BPS) model integrates a full range of biological, psychological, and sociocultural perspectives. A Critical Review of the Biopsychosocial Model states that BPS “provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care…[However, science] operates within a system that asserts there is nothing in the universe beyond matter and energy interacting in a time/space matrix...[and] we don't have a rational, empirical way of investigating non-observables...this restrictive view excludes from scientific consideration a great deal of what we regard as quintessentially human.”

Furthermore, scientific models must have “true predictive value…[e.g., predicting] a man's psychological state from his biological data or vice versa [and it must unite ] the disparate elements of human life in such a way as to legitimize a holistic approach [in which] materialism involves more than just matter and energy. Today, we accept that information, its transfer and manipulation…is a material matter…[so] manipulation of brain-based information…is a materialist theory of mind.”

As such, BPS can be considered a scientific model. I contend it also has predictive ability, e.g.:

• It can be predicted that a certain medication may have side-effects that present as psychological/psychiatric symptoms 
• Mental disorders may predict physical disease and vice versa
• Brain patterns may predict psychiatric problems
• Mental disorders make a substantial independent contribution to the burden of disease worldwide.

Wellness: A Proposed Definition

There has been much written about the importance of promoting "wellness" in value-based care. Yet there is no definitive definition of the concept. In this post I offer a conceptual framework for discussion in which I attempt to delineate many of the key factors discussed in the literature, along with my observations as a clinical psychologist. 

Proposed definition: Wellness is a measure of a person’s overall state of health, which is greatest when a person has and uses a set of abilities, desires, behaviors, and resources to avoid, manage, and cope with physiological, psychological (mental and emotional), and mind-body health problems to the extent possible.

The Following delineates some of the concepts in this proposed wellness definition.

1.      Health problems include (but not limited to):

1.1.   At-risk, acute, subacute, chronic, catastrophic, and end-of-life conditions.

1.2.   Illness, injury, dysfunction, disability, disfigurement, and debilitating distress with associated causes (e.g., contagion, trauma, genetics, etc.) and signs and symptoms (physical, emotional, behavioral, and cognitive).

1.3.   Mind-body (biopsychosocial) health problems in which psychological distress adversely affects a person’s physical health and vice versa.

2.      Requisite abilities, resources, and desires include:

2.1.   Abilities:

2.1.1.      Psychological capabilities that enable people to cope effectively with their health problems in a way that reduces the likelihood of denial, ignorance, self-deception, debilitating depression, irrational despair/discouragement and fear, hostility, blame, shame, and self-destructive behavior. These capabilities include focused awareness, rational and adaptive beliefs/thoughts/cognitions, open-mindedness, adequate drive/motivation/will and impulse control, self-determination, reasonable self-confidence, self-understanding, self-acceptance, sound/logical reasoning, reliable knowledge, and intelligence.

2.1.2.      Behavioral capabilities characterized by proactive, competent, and responsible actions that include adherence to evidence-based care plans/guidelines and making recommended lifestyle changes.

2.2.    Social, economic, and environmental resources (e.g., having access to quality healthcare, good health literacy, money, time, a healthy/safe living environment, social/family support, education and access to useful information, access to foods that support healthy eating patterns.

2.3.    Desire to live and develop one’s potential for a fulfilling life characterized love, learning, accomplishment, and other positive activities, experiences, and feelings.