Deploying a Patient-Centered Medical Home Cyberinfrastructure

Following is a scenario describes how multidisciplinary teams of healthcare professionals collaborating in a patient-centered medical home (PCMH), using an innovative cyberinfrastructure, can improve care outcomes and bring greater value to patients. This cyberinfrastructure has two software programs:

1. A computerized health agent (CHA) that enables patients and clinicians to connect to the PCMH network via the Internet
   
2. A next-generation electronic health record (EHR) designed for each clinician's specific role and special, as well as a next-generation personal health record (PHR), such as the PHPro™.

In this scenario John, a 40 year old high school teacher with type II diabetes, has been having trouble managing his blood glucose, blood pressure, and cholesterol levels, despite taking medication. He recently changed to a different primary care physician (PCP) who is involved in a PCMH network that uses the innovative cyberinfrastructure to help support and coordinate collaboration among a multidisciplinary team of clinicians.

Day 1: John calls his PCP to schedule the first office visit for the following week. After scheduling his appointment, the receptionist sends him instructions for accessing a comprehensive whole-person (mind-body) health assessment and joining the PCMH network. She also asks John to allow the results of the assessment to be sent automatically to the PCP; he agrees.

John then goes to his computer and opens his browser. He navigates to the PCMH web site and registers. After supplying the requested information and selecting a user name and password, he is automatically enrolled as a patient in the PCMH network. The CHA and PHR are then automatically downloaded and installed in his computer. The PHR then begins displaying a series of holistic health assessment questions on his screen.

After completing the detailed assessment, John's PHR automatically:

1. Analyses the data using its mind-body health logic engine
   
2. Stores the resulting biopsychosocial (biomedical and psychosocial) health information about securely in his computer in an encrypted data file
   
3. Generates a personal profile report providing him an integrated "big picture" view of his physical and mental health—past, present, and probably future—as well as evidence-based guidelines that enables him to understand his problems, risks, prognosis, and the relative pros and cons of different preventive and treatment options.

John starts interacting with biopsychosocial profile report offline. The report, which is comprehensive and easy to understand, includes:

• A description his medical and emotional problems and risks based on the information he input into the PHR
  
• A warning that he was under a great deal of stress due to problems at work and in his personal life
  
• An alert that his high blood pressure may be exacerbated by a side-effect of a supplement he is taking
  
• An easy to understand visual depiction of his health status, treatments, and significant life events on a timeline spanning many year
  
• A prognosis that give him realistic expectations by predicting how his health will likely be in the future if things continue the way they are going, and how likely his health will improve if he takes effective steps to control his current problems and prevent his risks from becoming problems
  
• Information therapy containing explanations and evidence-based recommendations about his health and what to do, including how his mental stress may be raising blood glucose and blood pressure levels, as well as targeted actionable recommendations that anticipates his needs
  
• A list of questions to ask his doctor to assist in shared decision-making.
  

John's CHA also sends a predefined subset of data from John's data file to his PCP's CHA via an encrypted data file. The PCP's CHA stores the file in his computer in a folder (directory) containing the data files of other patients currently in treatment; the files of inactive patients are in another folder. Whenever the PCP accesses his EHR and selects to view John's health information, his data file is retrieved and the information it contains is presented in an interactive report.

Day 12: John meets his PCP for the first time and the two of them discuss the results of the initial biopsychosocial assessment. The doctor then gives John his annual physical and tells John that the results of the blood tests will be sent automatically to his PHR once the doctor receives them. In the mean time, the PCP refers him to see a cognitive-behavioral psychotherapist, who is also in the PCMC network, to help him to handle his stress. After the office visit, John calls the therapist and makes an appointment for later that week.

Day 15: During his initial session with the psychotherapist, John authorizes an automatic electronic transmission of specific whole-person information from his PHR database to the therapist's EHR.

After the session, John returns home and clicks a few buttons on his PHR, which automatically sends the authorized health information to the therapist's database. At the same time, certain data from the therapist's database are sent to the PCP's database to help the PCP track and coordinate John's care. In addition, the PCP is alerted that his database is updated.

The therapist requires different health information than the PCP. Since the cyberinfrastructure is configured to distribute the appropriate data sets based on each clinician's specialty, the data received by the therapist includes detailed information about John's mental health that the PCP did not receive. This information includes analyses of the connections between John's thoughts, attitudes, emotions and behaviors; the nature of his current stressors and life problems; his coping skills and tendencies; certain observations of daily living (ODL) data; as well as his psychosocial history and significant past experiences. The therapist views this information through his EHR. He then adds his professional observations and psychological test results into EHR, as well as information that is sent from his EHR to the PCPs.

Day 19: After the PCP receives John's blood test results from the lab, those data are automatically sent to John's data file. An alert appears on John's as in icon on John's computer notifying him that new information is available for viewing via his PHR. Later that day John accesses his PHR and views his lab test results in language, graphs, and picture he can understand. As suspected, his A1c glucose levels are too high and his cholesterol levels are borderline. He clicks a link next to the abnormal levels and receives additional information therapy explaining the likely causes for his condition and suggesting steps for him to take. In addition, he receives an alert that sent to him automatically by his PCP's CHA; it instructs him to contact his PCP to schedule a follow-up visit ASAP, which he does online via the PHR.

Day 22: John goes to his PCP's office for the follow-up. He is prescribed new medications as recommended by the clinical guidelines displayed on the PCP's EHR. If his EHR implements the patient-centered cognitive support (PCCS) process, a virtual human model would be used to assist with guideline selection and generations of a holistic plan of care. A wellness coach working in the PCP's office, who uses a different version of the EHR, then sits with John, explains his self-management plan of care, and answers John's questions.

Day 23: John goes to his psychotherapist for his second session during which he and the therapist reviews his mental health report generated by the therapist's EHR. The report contains useful information that helps them determine treatment goals and methods for achieving those goals. This information also suggests a diagnosis and assists the therapist in establishing a treatment plan. The therapist then gives John a homework assignment. He is asked to use the self-help problem management guide on his PHR to assist him in managing stress, improving his coping skills, and developing more effective ways dealing with his personal problems. This assistance augments and supports the care rendered by his therapist.

Ongoing for the next 8 weeks: John continues meeting with his psychotherapist weekly and uses his PHR as a self-help tool. He also uses the PHR to collect observations of daily living (ODL) data on a regular basis. These data include his levels of stress, the situations in which the stress is high, his mood and thought processes when under stress, his behavioral reactions to the stress, medication use, physical activity levels, diet, as well as his blood glucose and blood pressure levels using home monitoring tools. The PHR analyzes these data automatically and displays a report explaining how John's mind and body are interacting, the changes taking place in his physical and mental health, trends, projections, and warnings. Similar data are sent automatically in encrypted data files by John's CHA to his therapist and PCP's CHA. Their CHAs then automatically update the versions of John's data file stored in their computers, thereby ensuring the most recent data available for viewing via their EHRs. In addition, the wellness coach receives a subset of the data, which updates John's data file stored in her computer. Each of these collaborating healthcare professionals are alerted whenever information on a patient is updated. When they view their EHR reports, the new data are automatically processed and warnings are displayed if newly discovered problems with John's health appear.

End of episode of care: Upon completion of his mental health treatment, John is alerted to use his PHR to do an outcome assessment in which a portion of the initial assessment is repeated. The results are calculated automatically revealing positive changes in his level of stress, mood, key cognitions (attitudes and beliefs), coping skills, as well as in his glucose and blood pressure levels; his cholesterol remains at a borderline level, however. The results are sent via his CHA to the PCP, psychotherapist, and wellness coach. In addition, the initial and outcomes data are de-identified and sent in a data file to a CHA connected to a research database, which imports the data. The data are then immediately available to collaborating networks of researchers and clinicians studying care outcomes and evolving the clinical guidelines for ever-better results.

Bottom line: This scenario exemplifies the benefit of delivering whole-person care in a coordinated and integrated manner supported by and innovative cyberinfrastructure consisting of (a) a CHA that connect clinicians and patients to a PCMH network via the Internet and (b) next-generation EHRs and PHR. The result is a happier and healthier person, who is a more productive employee, and who self-manages one's health more effectively. This benefits many by reducing utilization of healthcare services to lower employer overhead, insurer payouts, and the person's out of pocket expenses. In addition, healthcare professionals benefit from better outcomes, fewer errors, and more satisfied patients. And everyone benefits from greater peace of mind knowing that care is well-coordinated and delivered competently.

Related links:

• Curing Healthcare: Patient-Centered Medical Home: Gaining Traction
• Curing Healthcare: Patient-Centered Medical Home and Health IT

A Debate on Gradual versus Radical Change

Following is a discussion I'm having on a LinkedIn forum about adopting a very gradual approach to HIT evolution versus implementing a strategy promoting evolutionary leaps coming from disruptive innovation and a focus on radical change.

Someone wrote: I have proposed in the past and believe you might agree that a better approach would be to create a model of data sets that could be sent and received by providers in order to "qualify" their systems. This does still require a data standard but it allows the vendors to create their own tools and for innovation to thrive. Without a well defined data structure, we…will never be in a position to leverage those innovative tools such as cognitive support.

And I replied: While I agree that a model data set would be useful for qualification purposes, I've learned from experience that they tend to be "minimum data sets" with minimal usefulness, instead of being comprehensive/complete multidisciplinary data sets that approach "maximum usefulness." The problem with such minimal data standards is that it sets the bar way too low because vendors typically make that minimum their ultimate goal, rather than developing tools that can handle the maximum. I contend, therefore, that we ought to evaluate HIT tools in terms of (a) the depth and breadth of information they can manage cost-effectively and (b) whether that information enables patients and clinicians to make ever-better decisions by providing patient-centered cognitive support (PCCS). That is how innovation is sparked and meaningful change is encouraged; anything less promotes a glut of me-too commodities with minimal usefulness.

He also wrote: So, first we need to exchange information before we can take action on the data. In order to exchange the data we need a universally agreed upon data format. There are RHIOs and HIEs [i.e., organizations designed to enable data exchange in closed networks of providers] in place now that are functional but are not appropriate for a broader exchange of information. For the most part, those early implementations are proprietary systems that are scaled out to serve a region. While they have provided a valuable service, they need to adapt to a common data exchange that can be used to share data among other HIEs thus, a Nationwide Healthcare Information Network.

And I replied: Information exchange is certainly crucial. And I agree that intra-RHIO/HIE data exchange alone is not enough; there must also be inter-organizational information exchange across RHIOs/HIEs. While data and technology standards offer a way to handle information exchange challenges, they come with issues posing serious problems in terms of cost, effort, time, hassle, complexity, inefficiency, usability, reliability, information loss, political influence, etc. One innovative low cost solution we've been proposing is a publisher-subscriber node-to-node architecture with universal translation. I discussed these issue two years ago in a series of posts at this link.

He also wrote: Other than HIMSS desire to see CCHIT as the certification body, I believe their proposal is sound. That only brings us to the first step. I'm sure we would all agree that this will be an iterative process. ONC [The Health and Human Services' Office of the National Coordinator for Health Information Technology] needs to place a stake in the ground so we can move forward. Give us version 1 of a data object and we can start building Exchanges to get data to the EHR. Now we can start making use (even meaningful use) of the data and work toward improving healthcare. In time give us version 2 of the data standard and we will ratchet up functionality.

And I replied: Under the last administration—during the ONC NHIN initiative—$18.6 million was awarded to four large organizations, after deciding to renege on a promised 2/5 small business set-aside despite receiving many applications from small businesses around the country (see this link). Those millions, in the end, did not bring us any closer to an NHIN and left a very bad taste in the mouths of many innovative small businesses. Thus, it is important to guide ONC in guiding us by assuring that innovative ideas from "weak voices" (i.e., individuals and small businesses) be heard loudly and clearly, and be influential!

He also wrote: We have the data, we just need to improve the delivery and presentation of the data otherwise we'll be buried under information overload). We have the knowledge; we just need direction from the powers above. Give us clearly defined objectives and we will build an Information System that will be forward thinking and will enable us to use the patient's records as part of the treatment process. Keep us in the dark and we will go a hundred different directions, building dozens of perfectly functional systems that are each islands of information. One of the big failures of our healthcare system is not that we don't have the technology or the data; it's that we don't have the data where we need it when we need it.

And I replied: Yes we have data, but we do NOT have the data needed to create the necessary information and emerge the knowledge required to realize substantially improvements in care effectiveness and efficiency. And this goes well beyond the data distribution challenge. But even if we did have the necessary data, information, and exchange mechanisms, mainstream HIT tools would still NOT provide adequate decision making assistance because they fail to implement the patient-centered cognitive support process. Furthermore, I previously commented, there are serious problems with being overly reliant on restrictive standards on the "powers above."

So, we ought not to be squabbling about minimal data set and the use of conventional technology standards, but instead focusing our collective efforts on widespread collaboration to define the requirements for PCCS-enabled HIT that are able to manage comprehensive/complete multidisciplinary data sets with the potential to be maximally usefulness in both clinicians and patients/consumer in their decision making. I much rather see us going in "hundred different directions" in search of truly useful, disruptive HIT innovations, than to have the powers that be encourage adoption of the same old commodities that simply cannot do the job.

Having said that, there is a place for today's EHR and CPOE commodities, i.e., to define the strengths and weaknesses of the "AS IS" HIT model, so we can start building the "TO BE" model by adopting the most advanced and promising HIT tools that can overcome the AS IS model's deficits. These next-generation tools could be add-ons to today's commodity products, or they may be completely new types of tools that will replace what's currently available.

He also wrote: I'm an optimist and believe that we will pull it all together. The timeline that we've been given however is not realistic. How many practices are going to be in a position to satisfy the requirement that have not yet been issued before January 2011? The bonus payment that takes the 2011 reimbursement to $18,000 is based on meaningful use before January 2011.

And I replied: I contend that meaningful use of next-generation HIT can very well happen by 2011 and without great expense! Success will depend on the promotion and adoption of radical (disruptive, discontinuous) innovation. [Full disclosure note: My company is offering a novel cost-efficient way to exchange and evolve computational models in loosely coupled professional and social networks, which is an essential function for developing and deploying PCCS-enabled HIT.]

Meaningful Healthcare Reform: Challenges and Solutions

David Koitz of The Concord Coalition, who is a former analyst for The Congressional Research Service and the Congressional Budget Office, just published a provocative paper entitled: Electronic Record Keeping, Wellness Programs, and Care Coordination -- Would They Yield Real Savings, and When? While he makes many good points about the shortcomings and uncertainties of current strategies being proposed to realize meaningful healthcare reform, the paper overlooks certain important factors. Here are some excerpts from Mr. Koitz's paper, followed by my comments:

The Obama Administration has proposed a number of changes aimed at increasing efficiencies in the nation's health care system… But their potential to control rising medical costs should not be overstated. It is unclear whether…they would have a positive effect on the tendency of an entrenched fee-for-service health care system to encourage excessive services and other forms of volume driven expenditures.

Even assuming that they would have a positive effect, it is unlikely to be seen for many years...[and] health care costs are projected to grow by $2 trillion between now and 2018, and at an annual rate of 6.2 percent, or about one third faster than the economy.

The Congressional Budget Office (CBO) projects that the current effort to promote health IT would reduce health care spending by less than half of one percent over this period…[The] effort would do little to ease rapidly growing health care costs at a time when population trends are expected to exacerbate them. And while promoting wellness programs and care coordination may prompt healthier life styles and better treatment outcomes, studies suggest their potential to create long-term savings has not been demonstrated.

…Many health providers have not made the investment because the cost is greater than the potential savings in lower office costs or increased revenues…Overall, startup costs can exceed $40,000 per physician…No one really knows the true potential of health IT, not only to improve outcomes of medical care, but to control costs. Moreover, CBO's projections suggest that the development process would be lengthy with any real benefits not materializing for a number of years. And even if the rise in health care spending is slowed…any such effects would eventually diminish. CBO further points out that by improving adherence to treatment protocols, the proliferation of health IT could increase the amount of care provided, and thus offset the potential savings…For health IT to succeed, the security of those records is paramount.

...Wellness programs are intended to alter lifestyle choices that people make which contribute to ill health and disease, and that eventually may require medical intervention to ease or remedy… As with efforts to promote health IT, expectations of savings from wellness programs may be inflated…[Wellness programs] have been adopted by too many businesses, insurance companies, and health care providers with success to dismiss their significance in improving the nation's health…However, they too carry costs, and other factors can limit or offset their potential to contain the nation's health expenditures…[because] modification of the public's adverse behavior can take years of costly information campaigns and financial incentives, so the immediate impact on health spending may be limited…[and because such] efforts can lead to greater expense…[if preventive medicine leads] to additional services for some who are generally in good health and don't need costly medical care…[Futhermore,] spending on diseases caused by unhealthy behavior could decline substantially in the long run, but the impact on federal entitlement spending would rise as people live longer… As with health care IT, the investment in wellness is better justified as a public good than as a strategy for controlling overall costs.

Yet a third initiative suggested by the Administration involves…"care coordination," [whose] goal is to improve medical outcomes, limit hospital and nursing home stays, and reduce cost by…[delivering care in] a more comprehensive or holistic fashion… Medicare experiments and demonstrations with care coordination, disease management, and case management, have shown some positive impacts on the quality of service and patient satisfaction, but…none yet has conclusively shown it can reduce program costs significantly.

…The basic concept of the medical home model is to have a designated primary care physician coordinate all types of care and services needed by a patient -- preventative, acute, and chronic -- from a full range of potential providers, whether they be medical specialists, hospitals, rehabilitation facilities, laboratories, or other… Proponents believe that the continuity of oversight and better coordination of care will yield health care savings…[by reducing] health care spending by ensuring that services and treatments are based on a comprehensive view of the patient, follow evidence-based guidelines, and avoid unnecessary or duplicative tests and procedures.

However,…it relies on an adequate supply of primary care physicians, which appears to be lacking today…[In addition,] the medical home model could actually lead to increases in health care spending if patients responded by seeking more services -- or if payments to primary care physicians merely added to Medicare expenditures…The bottom line is that the impact on spending from improved care coordination of the chronically and multiply impaired patient remains unclear.

Another strategy…is the creation of voluntary accountable care organizations…[which] would allow groups of providers meeting threshold requirements to share in the savings they achieve from serving a minimum number of patients. There would be no "gatekeeper" or other change from current payment systems or benefits. Instead, the ACO as a whole would be responsible for the overall cost and quality of care for those patients assigned to it. Savings to be shared by ACO members would be calculated from an estimated baseline for serving its assigned recipients, who would remain free to seek medical care beyond the ACO… Proponents believe that ACOs would provide a flexible approach to fostering cost control by creating an incentive, not currently in existence, for providers to reduce unnecessary volume of services while improving quality of care…While the general concept has shown promise…success in broader applications would depend on several factors that are far from certain… Still, according to CBO, "By encouraging providers to begin developing more efficient systems for delivering care, this option could be an initial step toward changing providers' current systems of delivering care and could pave the way for greater changes in the future."

…[In conclusion,] with the exception of ACOs,…[these three initiatives] don't address head on the proclivity of our fee-for-service systems to profit from more rather than less service…For the most part, the predisposition of the nation's health care providers will still be to spend whatever the public's mélange of health care financing options permits, which in the aggregate operates with few dictates of what constitutes the most cost-efficient care…[These] initiatives are probably best seen as only the beginning of what likely will be a complex and stressful search for health care savings.

The concerns raised by Mr. Koitz are valid, but he overlooks certain important things about the potential of health IT (HIT) if it is used in meaningful ways. Specifically, it fails to consider the possibility of very low-cost EHRs and PHRs bundled with next-generation clinical decision support tools providing patient centered cognitive support (PCCS). These tools would deliver the following benefits:

• They would not only reduce duplication in services and error rates, but also help lower overall expenditures by promoting consistent delivery of the most cost-effective care based on the most recent research.
• They would guide clinicians and patients in selecting the treatment and preventive options demonstrating the greatest efficacy for the lowest cost and with the least risk.
• They would promote ongoing clinical outcomes research by feeding an evolving data warehouse that researchers and other collaborators use to develop and evolve evidence-based practice guidelines that are incorporated into the decision support tools.
• They would enable clinicians to override guideline recommendations and offer valid justifications for such variance. The variant procedures and their outcomes would be added to the research data warehouse, thereby (a) reducing the likelihood of unnecessary, inappropriate, ineffective, and inefficient care and (b) continually improving the guidelines themselves.
• By including a cyberinfrastructure promoting development and evolution of PCCS-based decision support models, those tools would become ever more reliable and useful.
• All of this would counter the tendency for fee-for-service providers to profit from the delivery of unnecessary or excessively costly care by replacing the fallacious notion that more (expensive) care is better care. Instead, the focus would be on identifying and delivering cost-effective care and rewarding providers who render such high-value products and services.
• It would also facilitate the medical home, ACO, and care coordination strategies—which I contend have great potential—as well as make wellness programs more effective.

Mr. Koitz also make a valid point about how keeping people healthier longer through wellness programs and medical homes is more likely to result in greater number of elderly with multiple expensive chronic conditions (even though they may occur later in life). I don't have a solution for this since there is no way refute the fact that our healthcare costs would be much lower if many more people were to die younger, and even more so if they were healthy and young when they died (a disgusting proposition!).

When it comes to dealing with security and privacy of personal health information (PHI), there are innovative solutions in which the patient/consumer is in control of one's own PHI without great expense (such as I describe at this link).

I also agree with Mr. Koitz in his assertion that significant short-term savings are unlikely, no matter what is done at this time. This sad situation, I contend, is the result of years of inaction; it is not due to any inherent shortcomings of strategies focused on deployment of next-generation HIT, medical homes, and care coordination. I say this after years of frustration. Similar strategies were recommended over 20 years ago, but our calls fell on deaf ears. If such strategies were implemented back then, we would have already been enjoying the benefits of lower cost and higher quality. In fact, we may very well have avoided our current catastrophic situation!

Radical transformation of our healthcare system is a MUST DO, and if our priorities are right, it's also a CAN DO. Moving slowly or continuing to wait is unacceptable since the situation will only worsen. While I'm hopeful that fundamental change is about to happen, my enthusiasm is tempered by our history. After all, there's good reason to believe that Winston Churchill was correct when he said: "You can always count on Americans to do the right thing — after they've tried everything else." We've been engaged in slow, incremental change for decades and it has failed miserably. It's now time to do the right thing…and that's NOT more of the same!

My next post debates gradual versus radical change.

Toward a Meaningful Definition of Meaningful Use (part 2 of 2)

As I discussed in a prior post, the federal government's $20 billion stimulus programs for health IT (HIT) —called HITECH—will fund the development of innovative HIT and use a "carrot & stick" financial approach to encourage clinicians to use HIT in meaningful ways. Unfortunately, the government did not clearly define term “meaningful use,” which has led to an intense debate over its meaning.

The definition I proposed was “using HIT to increase care value (effectiveness and efficiency) by providing ever-better patient-centered cognitive support.” This definition raises the bar over other definitions being offered because it focuses realizing the benefits of ever-increasing care value (effectiveness and efficiency), which is something mainstream HIT does not do.

In this post, I do four things:

1. Refine the patient-centered cognitive support (PCCS) definition
2. Compare and contrast PCSS with clinical decision support (CDS)
3. Clarify why PCCS capabilities in HIT tools should be a requirement of meaningful use
4. Explain why radical innovation is essential.

Defining Patient-Centered Cognitive Support

As discussed in a recent report by the National Research Council of the National Academies, PCCS is a computerized process that improves decision making by fostering profound understanding through use of a "virtual patient" model.

According to their definition, the PCCS process employs a computerized model of a "virtual patient" that reflects (i.e., is an "abstraction of") an actual patient. An HIT tool would use this virtual patient to guide the selection and analysis of data. These targeted data would be:

…relevant to a specific patient and suggest their clinical implications…[This would] provide decision support…that helps clinicians decide on a course of action in response to an understanding of the patient's status…[These tools would take into account] patient utilities, values, and resource constraints…[and they would] support holistic plans [of care]…These virtual patient models are the computational counterparts of the clinician's conceptual model of a patient. They depict and simulate the clinician's working theory about interactions going on in the patient and enable patient-specific parameterization and multicomponent alerts. They build on submodels of biological and physiological systems and also exploit epidemiological models that take into account the local prevalence of diseases. The availability of these models would free clinicians from having to scan raw data, and thus they would have a much easier time defining, testing, and exploring their own working theories. What links the raw data to the abstract models might be called medical logic—that is, computer-based tools examine raw data relevant to a specific patient and suggest their clinical implications given the context of the models and abstractions. Computers can then provide decision support—that is, tools that help clinicians decide on a course of action in response to an understanding of the patient's status. At any time, clinicians have the ability to access the raw data as needed if they wish to explore the presented interpretations and abstractions in greater depth.

In other words, the virtual patient used in the PCCS process is a computer program with advanced computational algorithms (mathematical and logical operations/steps). The algorithms "…incorporate physics (such as mechanical and electrical properties of tissue) and biology (from physiological to biochemical information) into a platform so that responses to varied stimuli (biological, chemical, physical, and…psychological) can be predicted and results viewed" [Ref: Oak Ridge National Laboratory].

Furthermore, a HIT tool implementing the PCCS process takes "…observations of an individual patient and relates them to a vast dataset of observations of others with similar symptoms and known conditions. By processing all this information, the model can simulate the likely reaction of the individual patient to possible treatments or interventions. Such tools will not only improve the quality of treatment offered to patients who are already ill or injured, but could also be used in preventive medicine, to predict occurrence or worsening of specific diseases in people at risk, for example through family history [Ref: Europe's Information Society Portal]. These simulations and predictions are used to support decisions by identifying the treatment and preventive approaches most beneficial to the virtual patient model, which would then be most likely to benefit the actual patient upon which the virtual model is based.

The HIT-PCCS Gap

Unfortunately, today's mainstream HIT systems do not employ the PCCS process. This, according to same National Research Council report, is a most serious HIT gap. The reason is that PCCS-enabled HIT tools are essential for helping clinicians to understand their patients' problems and needs without having to:

…spend a great deal of time and energy searching and sifting through raw data about patients and trying to integrate the data with their general medical knowledge to form relevant mental abstractions and associations relevant to the patient's situation…[Unfortunately, today's HIT systems] squeeze all cognitive support for the clinician through the lens of health care transactions and the related raw data, without an underlying representation of a conceptual model for the patient showing how data fit together and which data are important or unimportant…As a result, an understanding of the patient can be lost amidst all the data, all the tests, and all the monitoring equipment. In the committee's vision of patient-centered cognitive support, the clinician interacts with models and abstractions of the patient that place the raw data into context and synthesize them with medical knowledge in ways that make clinical sense for that patient.

Since they do not use the PCCS process, mainstream HIT tools do not:

• Help clinicians gain substantially greater understanding of their patients' situations (i.e., their strengths, weaknesses, risks, needs, and options)
• Enable patients to understand their own situations better.

Decision-making suffers as a consequence.

Eliminating the HIT-PCCS gap would enhance understanding and promote better shared decision-making about treatment, prevention, health promotion, and self-maintenance (see this link and this link). Because both clinicians and patients would be better informed through the PCCS process, the decisions they make would be more likely result in better outcomes (higher quality and safety) at lower cost. This would translate into increased care value (effectiveness and efficiency). In other words, using HIT tools that implement the PCCS process would help realize important benefits to individuals and society. These benefits include achieving the goals of both the Federal HIT Strategic Plan and the Institutes for Healthcare Improvement's "Triple Aim."

Federal HIT Strategic Plan Goals

PCCS-enabled HIT would help achieve the goals of the Federal government's HIT strategy. According to the Office of the National Coordinator for Health Information Technology, the American Recovery and Reinvestment Act (ARRA) Implementation Plan:

American patients and their caretakers will be the ultimate beneficiaries of the following activities aimed at achieving the President's health IT initiative to accelerate the adoption of health IT and utilization of electronic health records. All of the activities discussed in this section support the current two Federal Health IT Strategic Plan goals:

1. Inform Health Care Professionals: Provide critical information to health care professionals to improve the quality of care delivery, reduce errors, and decrease costs.
2. Improve Population Health: Simplify collection, aggregation, and analysis of anonymized health information for use to improve public health and safety [Ref: ONC HIT] 

Institutes for Healthcare Improvement's "Triple Aim"

PCCS-enabled HIT also helps achieve the goals of the Institute for Healthcare Improvement (IHI) recently proposed healthcare improvement design—called the Triple Aim—which has these three critical objectives:

• Improve the health of the population
• Enhance the patient experience of care (including quality, access, and reliability)
• Reduce, or at least control, the per capita cost of care [Ref: About the Triple Aim Initiative].

It is essential, therefore, that utilization of the PCCS process be included in the definition of meaningful use of HIT since sustainable healthcare reform benefits cannot be achieved without it!

PCCS and Meaningful Use of HIT

Based on the discussion to his point, it seems reasonable to conclude that HIT tools are used meaningfully if they employ the PCCS process in order to:

• Save clinicians time and energy by automating searching and sifting through a patient's clinical details and related research guided by a virtual patient model.
• Promote a deep and broad understanding of a patient's health status, including the interplay of biological, psychological, and social (i.e., biopsychosocial) influences—past, present, and future.
• Provide effective, personalized decision support regarding diagnosis, treatment, prevention, and health promotion. And this decision support would:
  
  • Account for patient preferences, qualities, and circumstances
  • Help improve overall care value
  • Continually evolve.

The following section discusses how PCCS provides superior decision support.

PCCS and Decision Support

A key question concerning PCCS and decision support is: What HIT tools provide decision support and is this decision support based on the PCCS process? To answer this question, let's examine two classes of HIT tools that offering decision support: electronic health records (EHRs) and clinical decision support (CDS) systems.

Electronic Health Records

One type of HIT tool providing some decision support is the EHR (and its electronic medical record counterpart). According to the Concise Guide to CCHIT Certification Criteria, certified EHRs deliver the following decision support capabilities (note that I combined ambulatory and inpatient EHR decision support criteria in the following list):

• Alerts and Warnings
• Provide alerts/warnings when
• There are abnormal test results
• Patient's vital signs fall outside the normal range
• Patient is allergic to a drug being ordered
• Drug or food interactions may occur
• A follow up test is recommended
• Patient is currently on a drug for which an allergy has been newly entered
• Drug side effects may occur based on diagnosis
• More appropriate or cost-effective therapy could be substituted
• Drug or food interactions may occur
• Medication dose is out of recommended range
• Patient is already on similar drug
• Patient is currently on a drug for which an allergy has been newly entered
• Order may be a duplicate
• More appropriate or cost-effective therapy could be substituted
• A follow-up or related order is recommended
• Immunizations are due or overdue
• Give the reasoning behind an alert, and allow override if appropriate
• Allow adjusting alert severity based on the clinician's role
• Report the effect of alerts on clinical decisions
• Provide dosing guidance based on:
  
  • Patient weight
  • Lab results
  • Scientific reference material
• Warn when a medication should not be given because of:
• Patient age or weight
• Pregnancy or mother who is nursing
• Block ordering medications via the wrong route (such as oral vs I.V.)
• Reminders
  
  • Provide reminders of recommended care that is due or overdue
  • Generate a list of patients for whom care is due or overdue
  • Generate letters to patients automatically for care that is due or overdue
• Identify patients for disease and wellness management according to guidelines
  
  • Based on age, gender, diagnoses, medications, lab results
  • Allow physicians to personalize the care guidelines for individual patients
• Generate patient education material for medications, diagnosis, procedures and tests
  
  • Allow tailoring for the patient
• For inpatient nursing staff:
  
  • Display for the nurse at the time of administering medications:
    
    • Any previous alerts
    • Patient's test results and allergies
    • Allow the nurse to use bar-code technology to assure "5 rights" (right patient, drug, dose, time and route)
  • Require the nurse to complete tasks, such as allergy verifications, prior to giving medications.

This list of criteria defines EHR-based decision support as: (a) warnings and alerts about abnormal test results and vital signs, medication issues, duplicate orders, follow-ups, immunizations, and certain therapy substitutions; (b) reminders regarding care due dates; (c) assistance with selection of basic general guidelines in certain situations; (d) general patient education materials; and (e) basic information for hospital nursing staff.

Such EHR-based decision support can be helpful in certain ways. However, since they do not employ the PCCS process, conventional EHRs do not:

• Search and sift through all of a patient's clinical data and the related research
• Take into account all the relevant aspects of patient's particular combination of personal preferences, qualities, and circumstances
• Examine the interactions between a patient's biopsychosocial health problems, threats, needs, and strengths
• Do an adequate job reporting quality measures (as indicated in a draft report by the National Quality Forum).

And as a result, they do not:

• Help emerge a deep understanding of a patient's particular health status and risks
• Generate detailed, personalized, holistic plans of care.

So, even when EHRs provide decision support, their failure to employ the PCCS process severely limits their value in improving healthcare quality and controlling costs. The same can be said, by the way, for personal health records (PHRs).

Today's EHRs (and PHRs), therefore, fall far short of what is needed for "meaningful use" because they do not employ the PCCS process.

Let us now examine another type of HIT tool providing decision support: Clinical decision support (CDS) systems

Clinical Decision Support Systems

Clinical decision support (CDS) systems, not surprisingly, go well beyond the typical EHR in the area of decision support, and some may be add-ons to EHRs. These CDS systems offer:

• Evidence-based diagnostic assistance
• Personalized rather than generic information based on a patient's unique symptoms and background
• In-depth evidence-based guidelines and clinical pathways.

Following are some examples of CDS systems:

• Problem-Knowledge Couplers - http://www.pkc.com/default.aspx
• Decision Support Systems - http://www.openclinical.org/aisinpracticeDSS.html
• Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes - http://jama.ama-assn.org/cgi/content/full/293/10/1223
• Clinical Practice Guidelines - http://www.openclinical.org/guidelines.html
• Computerized Clinical Practice Guidelines Systems Review - http://www.hcklab.org/research/computerized-clinical-guidelines/systems-review.htm
• Developing and deploying computerized clinical guidelines: barriers and solutions -http://www.ncbi.nlm.nih.gov/pubmed/12501817
• Clinical pathways - http://www.openclinical.org/clinicalpathways.html.

Do such CDS systems employ the PCCS process? Well, things tend to get a bit blurry here. A CDS system does implement the PCCS process if it uses evolving virtual patient models to help increase care value by:

• Automating data searching and sifting
• Enabling a deep and broad understanding of a patient's biopsychosocial health status
• Providing personalized decision support precise enough to account for an individual patient's preferences, qualities, and circumstances.

Even if certain CDS systems do utilize the PCCS process, this HIT class is not commonly used in clinical practice or by patients, which only adds to HIT-PCCS gap. 

Establishing Meaningful Use by Bridging the HIT-PCCS Gap

Bridging the HIT-PCCS gap means deploying mainstream HIT tools the implement the PCCS process. These tools would demonstrate a meaningful use of HIT, as discussed below.

Why Meaningful HIT Use Requires PCCS

The reason for making the PCCS process a requirement of meaningful HIT use is because it fosters profound understanding, supports evidence-based decisions, and promotes ever-greater care value by helping to answer questions such as:

• What are the person's current health problems and risks, taking into account (a) all pertinent physiological and psychological signs and symptoms, (b) all relevant biomedical and psychosocial influences, (c) any related treatments and medications received, and (d) the outcomes of care already rendered? What are the metabolic, genetic, emotional, and behavioral factors affecting the person's health and wellbeing?
• Is the person's health status being affected by a mind-body interaction and, if so, how is this interaction manifested (see this link for more)?
• How does the person compare to other people having the same kind of problems, qualities, and circumstances? How are the person's similarities and differences associated with clinical outcomes?
• What is the prognosis (likely outcome)—short-term and long-term, physically and psychologically—if the person makes no lifestyle changes?
• What should the plan of care be for treating the person's problems, or for avoid his/her risks from becoming problems—taking into (a) account all relevant research (including conventional allopathic and complementary and alternative approaches), as well as (b) the person's preferences, qualities, and circumstances? What are the risks, benefits, and costs of different plan of care options according to the research?
• When should certain tests, procedures, or prescriptions not be done/given because they were already done/given, or because they are unnecessary or inappropriate?
• If an error is made, how can it be rectified with least adverse impact on the person?
• When has a recommended test or treatment been missed or overlooked, and what should be done about it now?
• How should the care be coordinated for efficient, effective continuity of care across the healthcare continuum? Who should be collaborating in delivering the person's care and why? What particular personal health information can and should be exchanged with each particular collaborator?
• How effective is the care currently being rendered (refers to treatment process assessment)? When should a plan of care be modified, why should it be changed, and how should it be different?
• What was the outcome of each episode of care? What positive and negative factors contributed to the outcome?
• When does variance from (departure from, non-adherence to) a preferred practice guideline result in better outcomes for a certain types of patients than compliance to it? Why does the variance happen? Who is most likely to benefit from a particular guideline?
• What patient education/training is required for people with a particular condition in order to promote good self-maintenance?
• Is the patient adhering to the plan of care? If not, then what are his/her psychological blocks, economic and social obstacles, etc. and how can a patient become more motivated to follow the plan? When is it good that a patient does not adhere to a particular care plan and why?
• What about a person's social relationships are likely to improve or worsen outcomes? How should one's plan of care be adjusted accordingly?

Unless questions such as these can be answered validly and reliably, there is little chance that HIT decision-support will increase care value and realize sustained improvements in care effectiveness and efficiency. This is why bridging the HIT-PCCS gap is essential to the meaningful use of HIT.

How HIT Tools Can Provide PCCS

Creating and evolving innovative HIT tools that provide PCCS can be a daunting challenge. Accomplishing this goal would require innovative PCCS-enabled HIT tools that:

• Manage complete personal health information (PHI)
• Develop and using virtual patient models
• Support collaboration in loosely-coupled professional and social networks
• Fit the HIT tools into existing clinical workflows. 

Managing complete protected health information (PHI)

Innovative HIT systems that employ PCCS should securely manage (obtain, analyze, and present) complete biopsychosocial protected health information (PHI) over people's entire lifetimes. To be useful, this PHI should:

• Provide a detailed of picture the whole person, both mind and body, that go well beyond administrative (claims) data and provide a level of diagnostic precision absent from current day diagnostic codes
• Be relevant to both “sick-care” and “well-care”
• Shared wherever and whenever it is needed, and protect it via HIPAA-compliant security and "granular level" privacy methods.

Developing and using virtual patient models

It is important that these virtual patient models present decision-support information that is relevant to the specific patient (a) in the context of the current situation and (b) in relation to the whole patient and his/her predispositions. Following are examples of what the models should do.

The virtual patient models should obtain comprehensive PHI from any data streams, manual inputs, biometric sensors, and data stores (databases, files, etc.). In addition to patient status and health history, this information should encompass clinical process data, as well as results tracking, which includes outcomes data, guideline compliance rates, and the reasons for variance (departures) from the guideline recommendations.

The virtual patient models should use computational algorithms that analyze the data obtained in order to identify important patterns (e.g., trends, associations, clusters, and differences) useful for making predictions, linking diagnosis to cost-effective treatments, conducting health-related surveillance (biosurveillance and post-market drug & medical device surveillance), etc. And test the data for statistical relevance to determine which information provides reasonable explanations. The results of such analyses would help determine, for example:

• Whether a person's risk factors and changes in lab test results or vital signs indicate an imminent or worsening health condition
• How a person's attributes (e.g., gender, age, medical history, conditions, vital signs, symptoms, genetics, attitudes, etc.) compare to people in different diagnostic groups
• What treatment options and self-management approaches are most likely to result in the best outcomes for a particular person by accounting for the individuals particular attributes
• If a medication currently in the market is evidencing side-effects at a higher rate than found in clinical trials
• If clusters of a particular illness are widespread and indicative of a pandemic, or if the clusters are localized and indicative of environmental toxin, etc.

The virtual patient models should also provide feedback (including suggestions and reminders) and guidance (e.g., diagnostic aids and evidence-based guidelines) presented in personalized views that facilitate decision making, care coordination, and competent care delivery. This would help:

• Clinicians (a) make valid diagnostic decisions; (b) make evidence-based preventive and therapeutic determinations; (c) deliver appropriate care cost-effectively through efficient, safe and effective procedures; and (d) avoid under-testing, over-testing, under-treating, and over-treating their patients.
• Patients understand their diagnoses, risks, and treatment options, as well as learn how to self-managements their own health wisely and responsibly.

These models would, therefore, provide PCCS through useful personalized information that increases the likelihood of positive outcomes.

Supporting collaboration in loosely-coupled professional and social networks

Loosely-coupled professional and social networks (as opposed to technical networks) consist of people from multiple locations—who have different roles, responsibilities and experiences—who collaborate to make decisions beyond the knowledge or skills of any individual. These loosely-coupled networks would enable clinicians, researchers, patients, and informal caregivers to pool their wide diversities of knowledge, ideas, and points of view, thereby providing a larger collection of intellectual resource and offering access to a greater variety of non-redundant information and knowledge on which to base decisions.

For example, collaborating researchers and clinicians would foster the emergence of health science knowledge by analyzing, discussing, and interpreting care process and outcome data in light of patients’ diagnoses and qualities. This would promote the development and evolution of virtual patient models by transforming this knowledge into evolving evidence-based guidelines aimed at the continuous improvement of care effectiveness and efficiency.
Another important thing these collaborative networks can do is share and "play seriously with" different virtual patient models. That is, they would compare models and test them for their ability to reflect reality accurately; they manipulate the models to represent different scenarios, such as "what if" scenarios about the probability of future occurrences; and they discuss the assumptions and results the models produce. When they find models that disagree or generate invalid results, they examine the fundamental assumptions built into the models, looking for logical flaws and inconsistencies and debating about the assumptions and practical value of the model. By challenging the model's assumptions, useful counterintuitive insights often emerge, innovative thought is sparked, new questions arise, and compelling and unexpected issues are discovered. This means that sharing and playing with models is an effective path to innovation and value creation.

As such, these loosely-coupled networks provide the greatest opportunities for emerging creative ways to develop, evolve, and use the virtual patient models that provide PCCS.
These loosely-coupled networks should be supported by a cyberinfrastructure that, as described by the National Science Foundation,"…combines computing, information management, networking and intelligent sensing systems into powerful tools for…collecting and analyzing large volumes of data, performing experiments with computer models and bringing together collaborators from many disciplines." [Ref: NSF]. The cyberinfrastructure should be secure, economical, easy-to-use, and convenient.

Fitting the HIT tools into clinical workflows

PCCS-enabled HIT tools should assist clinicians in making decisions during their natural course of work, rather than requiring major adjustments of their workflows. This would increase the likelihood that clinicians will take advantage of that PCCS. 

The Need for Radical Innovation

The National Research Council’s report calls for radical change this way:

Change in the health care system can be viewed through two equally important
lenses—those of evolutionary and of radical change. Evolutionary change means
continuous, iterative improvement of existing processes sustained over long
periods of time. Radical change means qualitatively new ways of conceptualizing
and solving health and health care problems and revolutionary ways of addressing those problems. Any approach to health care IT should enable and anticipate both types of change since they work together over time.

Unfortunately, the HIT industry is focused on the gradual evolutionary change of existing products in lieu of radical leaps of change through development of new breeds PCCS-enabled HIT tools. This is why an abundance of conventional EHR commodities now crowd the mainstream market (see, for example, this link and this link), yet there is little attention given to CDS systems and almost no attention to PCCS.

As a result, there is a tendency to define meaningful use simply in terms of conventional HIT commodities, instead of “raising the bar” to new heights by requiring disruptive (radical, discontinuous) PCCS-enabled innovations. For example, the HIMSS definition of meaningful use, which was developed by a HIT vendors’ association, calls for the immediate use of current day EHRs and related HIT commodities, but doesn’t require CDS systems to be used until 4-7 years from now. Furthermore, the degree of decision support to be delivered by the CDS systems is minimal and falls far short of delivering the benefits of the PCCS process.

The meaningful use definition, therefore, ought to balance these evolutionary changes with the requirement for dramatically different types of software applications—a new generation of radical innovations—that employ the kind of PCCS able to help transform our healthcare system for the better.

Conclusion

Any good definition of meaningful use of HIT ought to include the implementation of the PCCS process to drive ever-evolving clinical decision support.

Since mainstream HIT tools to not employ the PCCS process, realizing such meaningful use will require substantial long-term commitment by diverse groups of collaborators in the development, use, and evolution of virtual patient models. If increasing healthcare value is truly our nation's goal, then there is no good alternative!

Employees tough to budge on workplace health

I was recently interviewed by an Australian organization called Return to Work Matters. It is directed by leaders in occupational medicine, return to work facilitation, policy development and support for professional networks. They have an interesting and informative web site at http://www.rtwmatters.org/index.php. Following is a copy of the interview, which also appears on the rtwmatters.org web site.

Who is least likely to participate in workplace health and wellbeing programs and why?

People who ignore or deny their health problems and risks are least likely to participate. That’s often because they have psychological “blocks” that drain their energy and willingness to focus on self-care and self-improvement. The blocks may be due, for example, to underlying depression. This depression, in turn, causes people to:

• Sleep too little or too much
• Be unable to concentrate
• Feel worthless and hopeless
• Lose their appetite or be unable to stop eating
• Have low frustration tolerance
• Become easily irritated and angry
• Even have self-destructive thoughts that they’d be better off dead.

For others, it may be anxiety and self-doubt, which leads to them denying that they have a problem. That’s because many people tend to convince themselves they don’t have a problem if they feel anxious thinking about it, or if they doubt they can improve the situation. While this coping strategy can relieve the anxiety temporarily, it is maladaptive because it does nothing to improve their situation and actually leads to worsening health by failing to manage the problem effectively.

People hampered by these psychological blocks are also less likely to be motivated by rewards and punishments because their failure to participate in a workplace health program is not due to laziness. These examples evidence a strong mind-body connection when it comes to self-managing one’s phsycial health and emotional wellbeing.

Here’s another thing to consider. Improving employees’ health and wellbeing requires lifestyle and psychosocial factors. Examples of psychosocial factors that affect return to work area include developing healthier behaviours (e.g. eating, exercising, sleeping and following doctors’ orders for managing existing conditions), as well as more adaptive emotions, rational thinking and effective coping skills.

That means employees must be able to continue making the positive changes after they leave work. As such, they must have the time, money, transportation and social support necessary to buy healthy foods, exercise adequately, get enough sleep, take required medications, control their stress and deal with personal problems.

What are the key things employers need to consider when planning and implementing a workplace health program?

In addition to health education, employers ought to have in place adequate resources—tools and people—to assess and deal with the psychological blocks I just mentioned. These resources include good mind-body health status assessments, as well as wellness coaches and counsellors. In addition, it can be beneficial to get the family of a resistant employee involved in the program as a means of social support. It’s also important to measure the program’s effectiveness in terms of enrollment and drop-out rates, as well as progress toward meeting participants’ health goals. And it’s important to measure a program’s performance and have a plan for continually improving its efficiency and effectiveness.

What do employers tend to forget about in terms of workplace health?

Employers tend to forget that punishments, incentives and threats do not work for everyone. Many people need compassionate counselling and a flexible program that addresses both their physical AND psychological needs.

What are the most effective methods for motivating employees who seem to have no interest in health and wellbeing?

They need a powerful reason to change their lifestyle despite the psychological blocks. Research has shown, for example, that ‘joy of living’ is a much more powerful motivator than ‘fear of illness and death’. Likewise, having self-confidence, being hopeful, alleviating depression and anxiety, learning to handle stress effectively and thinking rationally are factors associated with motivation.

Counselling is the best way to emerge these positive psychological characteristics in people lacking them by guiding changes in the way they think, feel and behave.

What suggestions do you have for organisations which lack the budget for health counselors?

One possibility is for employees with psychological blocks to receive psychotherapy outside the workplace, which has health motivation as a primary goal. Another possibility is to use cognitive-behavioural therapy self-help software, web sites and books.

In fact, I’m developing a holistic personal health record with a self-help component that incorporates cognitive-behavioral counselling and structured problem solving. This interactive software application helps guide a person to deal with health and other personal problems by understanding and changing their maladaptive thoughts, emotions and behaviours, which develops more effective coping skills.

Please tell us a bit about what keeps you passionate about workplace health.

My life mission is to help people across the globe lead healthier, happier and more productive lives. Workplace wellness programs have an important role to play in realising this goal.

Patient-Centered Medical Home: Gaining Traction

I want to commend the National Committee for Quality Assurance (NCQA), the American Academy of Family Physicians (AAFP), and other physician-based organizations involved in writing the Standards and Guidelines for Physician Practice Connections®—Patient-Centered Medical Home (PPC-PCMH™), which is available at this link.

I first wrote about the medical home concept in 2006 as being a key component for our healthcare crisis at this link. I followed it up in 2007 with a blog post at this link and then again in 2008 at this link.

The joint principles of the PCC-PCMH are:

Personal physician—Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice—The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation—The personal physician is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services and end of life care.

Care is coordinated or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the medical home.

• Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients and the patient's family.
• Evidence-based medicine and clinical decision-support tools guide decision making.
• Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
• Patients actively participate in decision making and feedback is sought to ensure patients' expectations are being met.
• Information technology (IT) is utilized appropriately to support optimal patient care, performance measurement, patient education and enhanced communication.
• Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.
• Patients and families participate in quality improvement activities at the practice level.

Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician and practice staff.

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. While aspiring to improve patient care, the four primary care groups envision implementation of the PCMH as linked to more rational (and higher) payment for primary care, which is in very fragile status in the U.S. The four primary care groups, aided by others, have held discussions with employers, health plans and the federal government to encourage the development of PCMH implementation/demonstration programs. In concert with the joint principles, the PPC-PCMH standards emphasize the use of systematic, patient-centered, coordinated care management processes.

These principles are both sound and doable! After seeing many good ideas evaporate due to lack of will and competing interests, I'm encouraged that strategies such as the patient-centered medical home are finally gaining real traction.

There are critics, however. For example, a recent article, titled Effectiveness of medical homes questioned, discussed how the “…effectiveness of medical homes as a tool for improving care was called into question at a hearing of the Senate Health, Education, Labor and Pensions Committee…[because of] ‘concerns about how to best design and implement such a model’…Some believe requiring physician referral for specialty services under a medical home model might introduce a costly and needless step to linking patients to the right source of care [arguing that] primary care is not always the most cost-efficient and effective provider for every condition and disease.”

I agree that critical evaluation of all healthcare delivery models (including the patient-centered medical home) is a good thing. But I do not agree with the criticism that primary care physicians (PCPs) may not be the best people to manage care coordination, even though certain PCPs will likely do a better job than others in coordinating care. As a group, however, PCPs, being generalists, seem to me to be the ones best suited for the job. Nevertheless, it’s important that our healthcare system enable PCPs to provide this crucial service by supplying them with effective health IT tools and paying them enough to spend the time necessary to coordinate and evaluate care being rendered to their patients. Over the long term, this will likely save money, especially when treating patients with chronic conditions, by eliminating duplication of tests and having multidisciplinary teams collaborating effectively.

Related links:

• Curing Healthcare: Deploying a Patient-Centered Medical Home ...
• Curing Healthcare: Patient-Centered Medical Home and Health IT
• Curing Healthcare: Four Interlocking Issues about Fixing American Healthcare

Toward a Meaningful Definition of Meaningful Use (part 1 of 2)

The federal government's $20 billion stimulus programs for health IT (HIT) is on its way. Called HITECH—for Health Information Technology for Economic and Clinical Health Act—it will fund the development of innovative HIT and use a "carrot & stick" financial approach to encourage clinicians to use HIT in meaningful ways. A debate now raging is how to define "meaningful use."[1] 

A Definition

Meaningful use, to me, means using HIT in ways that are of great value to the patient and other healthcare consumers. It doesn't matter what types of software tools are used, what communication infrastructure is used, what standards are used, or what certifications are used. It just means that the using HIT should result in ever more effective and efficient (i.e., ever greater value) care delivery.

Increasing care value is unlikely unless clinicians obtain information and guidance assisting them in answering difficult questions, making tough diagnostic and treatment decisions, collaborating effectively, and taking competent action. In addition, healthcare consumers (patients, clients, customers, etc.) would benefit from assistance in selecting the most cost-effective treatment options for existing conditions, and in managing their own health in ways that prevent illness, control chronic conditions, and increase their well-being.

Such assistance is crucial because the unaided human mind simply cannot handle the overwhelming details and complexity of many health problems. Consider the following section which contains important quotes from Dr. Larry Weed and others:

The volume of clinical information expands exponentially with more than 150,000 medical articles published each month in more than 20,000 biomedical journals. Healthcare providers struggle to stay current with the clinical information, but inevitably become overloaded. This may contribute to the slow adoption of evidence-based research in clinical practice. There is just too much clinical information being generated for providers to incorporate into their internal base of knowledge.

As a group, healthcare providers care about patients and take pride in doing an excellent job in caring for their well-being. Nevertheless, the "…task of knowing every detail is way beyond the [ability of] human mind… For example…diabetes care ought to take into account any of 120 management options and 380 possible patient conditions associated with the disease. …the unaided mind cannot reliably recall all the causes or management options that should be considered for each patient, nor can it recall all the findings in the patient needed to discriminate among those options, nor can it reliably match findings to options under the time constraints of practice."

In addition, "…most physicians are able to take into account only a portion of the diagnostic and management options potentially relevant to their patients and only a fraction of the evidence needed for choosing among those options. …Physicians do little better with the usual aids to medical decision making, such as practice guidelines and use of Internet resources. Those aids provide general knowledge, but do not ensure that the physician will recall all the data or successfully link it with a particular patient's specific problem." Problems that cross specialty boundaries and require multiple specialists, yet the current healthcare system does a poor job at supporting communication between providers and assuring continuity of care. And primary care physicians are not equipped with the information tools necessary to grapple with the information overload, nor do they have a system for coordinated care within which to function.

"Because physician time is expensive and scarce, their initial workups can be meager [as they] …act according to their own preconceived notions about what history, physical, and laboratory findings are worth checking. Equally idiosyncratic are the conclusions they draw from whatever data they select. Both selection and analysis of data are influenced heavily by their medical education, prior clinical experience, specialty orientation, contradictory clinical guidelines, financial concerns, cultural background, personal biases, and day-to-day time constraints, all of which vary enormously among individual practitioners."

With this in mind, consider the recent report by the National Research Council of the National Academies, which concluded that a serious gap in health information technology (HIT) today is the failure to deliver patient-centered cognitive support (also called consumer-centered cognitive support). According to the report:

During the committee's discussions, patient-centered cognitive support emerged as an overarching grand research challenge to focus health-related efforts of the computer science research community, which can play an important role in helping to cross the health care IT chasm...Today, clinicians spend a great deal of time and energy searching and sifting through raw data about patients and trying to integrate the data with their general medical knowledge to form relevant mental abstractions and associations relevant to the patient's situation…The health care IT systems of today tend not to provide assistance with this sifting task…[We need] computer-based tools [that] examine raw data relevant to a specific patient and suggest their clinical implications given the context of the models and abstractions. Computers can then provide decision support—that is, tools that help clinicians decide on a course of action in response to an understanding of the patient's status. At any time, clinicians have the ability to access the raw data as needed if they wish to explore the presented interpretations and abstractions in greater depth…The decision support systems would explicitly incorporate patient utilities, values, and resource constraints…They would support holistic plans and would allow users to simulate interventions on the virtual patient before doing them for real.[2]

It's logical to conclude from the information above that patient-centered cognitive support is the kind of value-enhancing assistance needed, but largely missing from, today's HIT.

Thus, "meaningful use of HIT" can be translated into "using HIT to increase care value (efficiency and effectiveness) by providing ever-better patient-centered cognitive support."

The HIT Gap and How to Fill it

Is it reasonable to expect the healthcare industry to fill the patient-centered cognitive support gap? According to a recent report by the Congressional Budget Office titled, Evidence on the Costs and Benefits of Health Information Technology,[3] HIT systems have the potential to provide such cognitive support by, for example, reminding physicians to schedule tests, helping them diagnose complicated conditions, assisting them in implementing appropriate treatment protocols, and promoting research focused on developing and evolving evidence-based guidelines.

A Different Definition from HIMSS 

While I proposed a path of radical HIT innovation, the Healthcare Information and Management Systems Society (HIMSS) Board of Directors recently proposed a more conventional path, which includes these seven HIT requirements:

• EHR certification by the Certification Commission for Healthcare Information Technology (CCHIT)
• Standardized patient data conforming to the Healthcare Information Technology Standards Panel's (HITSP)
• Interoperability specifications based on the Integrating the Healthcare Enterprise's (IHE) frameworks
• Use of an EHR including CPOE (computerized practitioner order entry) functionality
• Electronic exchange of patient summary information as specified in the Continuity of Care Document (CCD) standard
• Support for a subset of existing National Quality Forum-endorsed process and care measurement
• Use of clinical decision support (CDS) systems providing clinicians with clinical knowledge and intelligently-filtered patient information to enhance patient care.[4]

Interestingly, only item #7 relates directly to the delivery and continual evolution of patient-centered cognitive support, even though it barely scratches the surface as to what a CDS system should do. And while item #6 is also important, the subset of measures is grossly inadequate for delivering and evolving patient-centered cognitive support. Furthermore, it doesn't push for significant implementation until 4-7 years from now.

Item #1 refers to an expensive certification process that stifles radical innovation by forcing out small HIT companies, including open source developers. I can see the benefit of testing HIT vendors product to see how good they work (like Consumer Reports does with cars and appliances), but vendors shouldn't have to pay for it (Consumer Reports doesn't make the manufacturers pay). Instead, a government agency (FDA?) could probably do it. Furthermore, the certification process to which HIMSS refers has nothing to do with patient-centered cognitive support.

Items #2 & 3, which refer to data and technology standards, present a double-edged sword for reasons I discuss in a series of posts starting at http://curinghealthcare.blogspot.com/2007/05/art-of-health-knowledge-creation-use.html. Rather than limiting HIT developers to a specific set of global standards, it would be better to allow them to use local data standards and any technology standards, as long as their tool can exchange required information with tools other vendors develop. That's because well-designed innovative HIT tools should be able to provide patient-centered cognitive support without the constraints of particular data and technology standards.

Items #4 & 5 refer to particular types of HIT, which I agree are important. The problem with making exiting EHRs, CPOEs, and CCDs a requirement for "meaningful use" is (a) the current crop of HIT provides little, if any, patient-centered cognitive support and (b) this constraint may hamper innovation by impeding the invention of alternate types of HIT able to provide superior cognitive support.

Conclusion 

HIT is used meaningfully if it focuses on increasing care value (efficiency and effectiveness) to patients and other healthcare consumers by providing ever-better cognitive support. The smart path to meaningful HIT use is one that promotes the kinds of radical innovation that enable widespread collaboration and the application of good science focused on providing continually evolving patient-centered cognitive support. Following this path means (a) accepting that the unaided human mind, no matter how competent, simply cannot handle the incredible amount of complex information that must be processed to make wise decisions in difficult situations, (b) doing more to link scientific research and clinical practice, and (c) encouraging truly creative HIT solutions. 

The discussion is continued at this link.

References:
[1] http://www.lexuniversal.com/en/news/7764
[2] Stead, W.W. and Lin, H.S. (Eds.) (2009). Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. Committee on Engaging the Computer Science Research Community in Health Care Informatics; National Research Council from http://www.nlm.nih.gov/pubs/reports/comptech_prepub.pdf
[3] Congressional Budget Office. (2008, May).
Evidence on the Costs and Benefits of Health Information Technology. Retrieved from http://www.cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf
[4] http://www.himss.org/ASP/ContentRedirector.asp?ContentID=69148&type=HIMSSNewsItem

Case for a Collaborative Health-Support Software System - Part 3 of 3

Introducing the ReAsure HealthNode™ Software Technology

In my previous two post (click here for the 1st in the series), I (a) presented a case for using collaborative health-support software systems in loosely-coupled networks of healthcare professionals and consumers and (b) explained how to implement such systems and networks in a way that increases value to the consumer. In this post I introduce a next-generation software system we've been developing for quite some time, called the ReAsure HealthNode™ software technology, which is designed to help these networks transform our current low-value, fragmented, healthcare industry into a high-value one by enabling people in widely scattered localities to:

• Collaborate around personalized health-support software
• Evolve those programs
• Use the programs to help prevent, treat, and manage health problems efficiently and effectively …

Resulting in:

• Better care coordination
• Greater consumer-centered cognitive support
• superior shared decision-making
• More competent self-maintenance (self-care).

The system utilizes innovative methods and the patented CP Split™ technology[1] to deliver a unique set of benefits and advantages, which follows.

Benefits and Advantages #1:
A Simple, Flexible, Low-Cost Way to Exchange Health-Support Software and Data Files

The ReAsure HealthNode™ software apps provide a simple, flexible, low-cost way to exchange health-support software and data files rapidly and securely via peer-to-peer mesh networks. These networks operate in a node-based[2] communications architecture in which each computerized device loaded with a ReAsure HealthNode™ software module and a health-support software program becomes a node connected to other nodes in the network. Each node, furthermore, has publisher-subscriber functionality,[3] which means certain nodes serve as publishers and other as subscribers. The publisher nodes send the files and the subscriber nodes receive them. The system uses a "desktop-to-desktop" (application-to-application) architecture and exchanges the files via FTP (file transfer protocol), e-mail attachments, or other methods of file transfer through Internet connections.

At one end of the connection, the node serving as the publisher must authorize the transfer of a health-support software file and/or data file by authenticating that each subscriber node is allowed to receive them. At the other end of the connection, the subscribing nodes must allow the publisher node to deposit any necessary file(s) into the subscriber's computer.

Exchanging Health-Support Software Files

The health-support software files designed for the ReAsure HealthNode™ apps consist of particular types of software templates. These templates are electronic files that run (execute) the health-support software by applying particular rules (algorithms) consisting of mathematical formulas, logic, text functions, and formatting instructions (which reflect the software's underlying model). The software templates have two basic functions:

• Create Data Files (also called "content files") for distribution, which is a publisher function
• Consume (extract data from) the content file and render it in reports or enable new data to be input, which is a subscriber function.

The health-support software template files are sent from the publisher node to its subscribers when the initial connections are made, and again if the templates have been modified. The files are also exchanged when network collaborators want to compare and examine the different software programs, discuss their findings, debate the pros and cons of competing programs, modify the programs, build new programs, etc. This process is crucial for the software's evolution (continuous improvement) and can be facilitated by giving the nodes access to knowledge management software containing a virtual forum.[4] The oil & gas industry, for example, has used a node-based virtual forum, which enable participants to share lessons learned, best practices, after action reviews, drilling reports, and health & safety alerts on deep water drilling rigs around the globe.[5] Such a program can be applied to healthcare to help collaborators evolve the health-support software.

Exchanging the Data that the Software Uses

In addition to exchanging health-support software files, the ReAsure HealthNode™ Network system uses node networks to exchange and transform data files containing consumers' health information. Figure 1 (below) describes the basic components and processes of its node-based data file exchange method, which are explained following the figure.


Click image to enlarge

Starting on the left of Figure 1, the Software Template File box depicts the health-support software template file and the arrow through it depicts the publisher node sending the file to the subscriber nodes as discussed above. Note that ReAsure HealthNode™ apps can also interface with other software programs via application programming interfaces APIs[6] (which is not depicted in the Figure 1).

The Node as Publisher box in Figure 1 depicts a node that:

• Uses a health-support software template to:
  • Acquire data and information (content) from specified sources, as depicted by the arrow from the Data Input to Data/Information Sources box, which is a template input function. The content may include numbers and text, as well as links to electronic documents, images, and web sites.
  • Process (manipulate, transform, and organize) the content as defined by the template's algorithms and then package that content in encrypted, delimited (e.g., comma separated value)[7] content file (Data File). Since the content file do not contain any formatting instructions or "markup tags,"[8] they are very small to transmit and efficient to use. These template output functions are depicted by the arrow to the Content File box.
• Uses its publisher module to transmit the content file to its subscribers via e-mail or any other methods, as depicted by the arrow to the Node as Subscriber box, which is a publisher node transmission function.

The Node as Subscriber box depicts a node that:

• Uses its subscriber module to retrieve the data & information from the content file, which is a subscriber node input function, as depicted by the arrow coming out of the Content Files box.
• Uses a health-support software template to:
  • Format the content and displays it in interactive reports, which is a template output function, as depicted by the arrow to the Report Display box.
  • Enable a person to enter new and modified content through its user interface, as depicted by the arrow to the Data Input box, which is template input function. Note that his added or changed content may be used to update the existing content file stored locally in the person's computer, as depicted by the arrow to the Existing Local content file box, or the content may be exported to any databases or other data sources, as depicted by the arrow back to the Data Input to Data/Information Sources box; both of which are template input functions.

Since the content files are typically much smaller than the software template files, transmitting the content files as encrypted e-mail attachments has several advantages:

• It provides a convenient and transparent automated method that accommodates everyone's needs—from people with continuous broadband to those connected to the Internet only occasionally, as well as those using low speed dial-up services
• It saves money by eliminating the need for expensive hardware, high-speed networks, costly IT support, and complex software systems.

Figure 2 (below) depicts how a network of nodes operates to exchange information.


Click image to enlarge

Following is a description of the six steps shown in Figure 2.

Step 1: Line #1 depicts the node at the top retrieving content from databases (including EMR/EHRs, laboratory systems, etc.), as well as from electronic files and other sources, and then processing that content to create a content file using node functions defined in its health-support software file.

Step 2: The solid blue arrows of line #2 show the node at the top using the publisher functions to send content files via encrypted e-mail attachments to the node at the upper right, the nodes on the left, and the node at the bottom.

Step 3: This dashed arrow (line #3) shows the top node, after sending content files to the node on it left, subsequently receives the content file from that same node and retrieves it via its subscriber functionality. This means both these nodes invoke their publisher and subscriber functionality.

Step 4: These two nodes receive and retrieve content files; only their subscriber functionality is invoked.

Step 5: These dotted arrows show content files being passed sequentially from one node to the next, with each node adding to or modifying the files it receives, before sending extended content files to the next node; their provider and subscriber functions are invoked.

Step 6: The bottom node receives content files from two other nodes via its subscriber functionality. After forming a composite content file from the accumulated content, as defined by its health-support software templates, it sends the composite content file back to the node at the top using its publisher functionality.
Thus, based on Figures 1 and 2, networks of nodes using publisher subscriber modules and health-support software can:

• Exchange and evaluate software template files
• Create and share content files
• Generate personalized, interactive reports
• Modify the contents file and then reuse it to generate updated reports or export it to other data stores.

Following is a practical example of a collaborative health-support software system in action.

A Practical Example

Imagine a consumer having the ReAsure HealthNode™ modules in his computer, along with a health-support software program. When he installed the node modules, he went through a registration process during which he sent requests, as a publisher, to the nodes of people to whom he wants to send certain of his health information. He also sent requests, a subscriber, to people from whom he wanted to receive information. In addition, he received requests from others who want to receive his health data (i.e., they subscribed to him). The nodes used e-mail to transmit the content files, so the e-mail addresses of the corresponding nodes were stored during registration. As each request was approved by the appropriate parties, the transfer of software template files and content file began.

Now, whenever he wants to sends particular data to the healthcare providers he authorized as his subscribers, he click his mouse to initiates certain publisher node functions, which instruct his node to:

• Retrieve and decrypt his content file
• Extract from his content file the particular data authorized for each provider; these authorizations are based on the provider's "role" (e.g., the provider's area of specialty)[9] Pack the extracted data into other content files and encrypts them
• Attach the content file to e-mails and sends them to the appropriate providers.

Upon receipt of the e-mails by his providers, each of their subscriber nodes:

• Retrieves the content file from the e-mail
• Decrypts the content file
• Extract the data from the content file
• Exports the data to the provider's electronic medical record system.

All these steps taken by the publisher and subscriber nodes are done automatically.

In a similar manner, the consumer may want to obtain data from a provider or lab, that is, he may want to be one of their subscribers. If the provider (or lab) has a ReAsure HealthNode™ and the registration process is completed, the consumer would send a request to their nodes for a content file containing certain information. In this scenario, the consumer's node uses its subscriber functionality, and the provider (or lab) node serves as the publisher.

Once the consumer's node receives the e-mail with the content file attached, it automatically retrieves and decrypts the content file, extracts its contents, and merges the new data into his own (locally stored) content file. Depending on the software rules, the data may replace (i.e., overwrite) existing data in his content file or it may be added to the existing data. His content file can then be accessed, formatted, and presented by any appropriate health-support software program, such as the Personal Health Profiler™.[10]

In yet another scenario, a provider may request particular data from the consumer, or certain rules the guide in the consumer's node might be executed on behalf of the provider (e.g., if the consumer has diabetes, a rule might tell his node to send his glucose readings to his primary care physicians, endocrinologists and wellness coach once a week). In this case, the consumer's node is once again the publisher, which automatically extracts those data from his content file and sends it to the subscriber's (i.e., providers') nodes.

Data Transformation and Translation

Transmitting content files between nodes and rendering them as reports is only part of the process. What happens when a publisher node sends a content file to subscriber nodes utilized by people who use different terminologies, speak different languages, or have different data storage and presentation requirements? How are the contents of the content file transformed and translated to meet the diverse needs of everyone in such loosely-coupled networks?

Transforming Data

Data often has to be transformed when being sent from one database to another. This happens when, for example, the databases have different table field[11] names (e.g., "birth_date" and "dob") or data formats/syntax (e.g., whether or not dashes should be included in a phone number). What is required, therefore, is either to force everyone to use the same data standard, such as transforming everything to XML[12] using a common "schema" (data structure). Another is to transform the original data names and formats so the data are received in the proper configurations.

XML data standards can be used in the node network to transform data, and the content files can be constructed of data transmitted in XML files. But simpler and most efficient ways include having rules included in the node functionality that instruct:

• The publisher node to do the necessary data transformations prior to packing the data into the content file before sending it to its subscribers
• The subscriber nodes to do the transformation upon receipt of the content file
• Intermediate nodes make the transformations as the content file passes through them.

Note that these transformation methods require that the publisher and subscriber nodes be notified in advance as to the required transformations. This notification process can happen during the registration or upon a subscriber node's request for data from the publisher.

Translating Information

When people in loosely-coupled networks share information there is often the need for it to be translated. In addition to language translation (e.g., English to Spanish), the issue of terminology translation must be addressed. This refers to the problem that occurs when different people use different terms (their local standards) to refer to the same concept.

One common strategy used to avoid such problems is to force everyone to adopt the same global terminology standards[13] by agreeing on one set of terms (semantics). While setting arbitrary global standards for health-related terms is a way to foster widespread communications between people from different regions, organizations and healthcare cultures/communities, there's also a downside to eliminating the local standards people rely upon, i.e., they lose information due to reduced semantic precision and nuance.

Take, for example, the term "high blood pressure;" there are 126 different terms referring to this concept of elevated blood pressure levels. These terms include "malignant hypertension," which refers to very high blood pressure with swelling of the optic nerve behind the eye; it's a condition usually accompanied by other organ damage such as heart failure, kidney failure, and hypertensive encephalopathy. "Pregnancy-induced hypertension," on the other hand, is when blood pressure rises during pregnancy (also called toxemia or preeclampsia). These are very different types of hypertension. So, while referring to a person's condition using a global standard term such as "hypertension" clearly conveys that the person has high blood pressure, the standardized term loses important details found in the more detailed local standard terms. These lost details, in turn, could very well affect treatment decisions and outcomes. So, there is a good reason to have multiple terms for a health-related concept.

Furthermore, relying on global standards are problematic because, as standards evolve, it can be very difficult and costly to change the global standards Consider, for example, the clamor over by switching to the new ICD-10 global standard of diagnostic terms (codes), which have evolved from the ICD-9 standard.[14]

It would be much better, therefore, to keep local standards, support their evolution, and use the data translation described above to ensure everyone gets the information needed using the terms they need and understand. In a node network, this can be accomplished in a similar way data transformation occurs, but instead of transforming the data, the terms that the subscriber node requires either replace, or are added to, the terms in the original content file.

Composite Reporting 

In addition to modifying a content file data through transformations and translations through node networks, the nodes support composite reporting. Composite reports consist of information sent from multiple publisher nodes to a single subscriber node. The subscriber node takes all that information and combines it into a single integrated content file, which is then used to generate composite reports containing information from multiple sources.

For example, let's say a primary care physician (PCP) wants to keep track of the treatment a patient is receiving from several provider specialists. The PCP's node, which serves as the subscriber, would send a request for certain data from all the patient's specialists. Upon receipt of the data request, the specialists' nodes, which serve as the publishers, retrieve the requested data from their different electronic health record databases and send the data automatically to the PCP's node. The PCP's node then incorporates the data into a composite report tailored to the PCP's needs and preferences, and then presents the report on screen for the PCP to view. The PCP's subscriber node could also be instructed to request data from the publisher node connected to the patient's personal health record and, upon receipt (and as authorized by the patient), add the data into the same report as authorized by the patient. Likewise, a consumer using the Personal Health Profiler™ software can create composite reports in a similar manner from data sent by multiple provider nodes.

Protecting Personal Health Information

With all this personal health data being sent around, a powerful method is needed to protect people's privacy. While encryption and authentication handles security issues (e.g., making it safe to send content file by e-mail), it doesn't deal with privacy issues (i.e., who is allowed to receive a person's health information). Instead, protecting the privacy of information sent by consumers' nodes requires strategies such as transmitting "limited data sets" and enabling "granular level" of control. That is, consumers should be able to implement one-time authorization to share certain parts of their content files with specific types of providers. They should also have granular control over whom, if anyone, gets to see their information by authorizing particular types of providers to receive particular pieces of information. Warnings and alerts inform the consumer if certain information not being authorized ought to be shared with certain providers who need those data to help make diagnostic and treatment decisions.[15] The Personal Health Profiler™, for example, deploys these privacy safeguards.

Benefits & Advantages #2:
An Elegant Way to Maintain a Complete and Evolving Data Set 

A second set of benefits and advantages of the ReAsure HealthNode™ Network system is its ability to maintain a complete and evolving data set that excludes nothing. That is, every possible piece of health information—about one's health status, risks, conditions, treatments received, the clinical outcomes (results) and costs of the treatments, etc.—can be collected, stored and used over a person's entire lifetime. It does it using an indexing and categorizing method similar to the Dewey Decimal classification system libraries use to organize books and magazines.

This all-encompassing method enables rich, detailed health-support software to be built. And it also permits development of holistic (mind-body-environment) health-support software that improve care value by promoting greater understanding of a consumer's health problems, threats, and needs. The holistic approach provides feedback, guidance, and instruction about people's:

• Signs & symptoms[16] and their possible relationship to medications side-effects treatment procedures, including complementary and alternative medicine[17]
• Psychological (emotional, cognitive, and behavioral) health and its relationship to biomedical conditions (e.g., the effect of mental stress of blood glucose control in diabetic persons)[18]
• Genetic markers and the associated health risk factors[19]
• Health trends based on health status changes and lab test results over time
• Methods for coping with and solving personal problems.

Benefits & Advantages #3:
A Way to Increase Care Value to Consumers while Protecting Populations

And a third set of benefits and advantages refers to the ReAsure HealthNode™ Network system's ability to support evidence-based research across all healthcare disciplines focused on improving healthcare value to consumers, and to protect populations through surveillance and support of emergency personnel.

Increasing Care Value to Consumers through Evidence-Based Research

Increasing and sustaining care value to consumers requires a simple, flexible, low-cost way to exchange health-support software; a convenient, secure, economical way to exchange the data used by the software; and an effective, efficient way to maintain a complete and evolving data set. By adding the system's ability to de-identify consumers' health data[20] to these previously discussed advantages and benefits, it becomes apparent that the ReAsure HealthNode™ Network system is ideal for researchers involved in creating, studying, and evolving high-value evidence-based guidelines across all healthcare disciplines (both sick-care and well-care, as well as conventional and complementary & alternative care[21]).

This kind of research is essential for development of evidence-based healthcare decision support systems utilizing quality metrics, practice guidelines, knowledge services and tools, and continuous quality improvement feedback loops.[22]

Protecting Populations

• The ReAsure HealthNode™ Network system also addresses the need to protect populations through:
  Comprehensive biosurveillance and post-market drug & medical device surveillance[23]
• Support for first-responder and trauma center staff during disasters[24][25]
• Has no "single point of failure,"^, which leaves centralized systems vulnerable in disaster situations.[26][27]

Summary and Conclusion

Collaboration among loosely-coupled networks of healthcare providers, researchers, and consumers using health-support software is an essential strategy for increasing healthcare value. ReAsure HealthNode™ Network system demonstrates how to enable efforts to bring consumers high value care.

We welcome any feedback and opportunities for collaboration.

References and Notes

[1] http://cpsplit.typepad.com/
[2] A node is an electronic device (e.g., a PC, laptop, cell phone, and hand-help device) attached to a network, which contains a software module enabling it to send, receive, or forward information across that network.
[3] http://cpsplit.typepad.com/cp_split_technology/2006/12/node_network_us.html
[4] A virtual forum enables people share information over the Internet, online or offline, through “threaded” discussions in messages on the same topic are grouped together for easy retrieval and reading.
[5] http://nhds.com/dwd/kmintro.htm
[6] http://en.wikipedia.org/wiki/API
[7] http://en.wikipedia.org/wiki/Delimited
[8] http://en.wikipedia.org/wiki/Markup_language
[9] Each provider’s role is established during the registration process and used by the node thereafter.
[10] http://curinghealthcare.blogspot.com/2008/04/personal-health-profiler-part-1.html
[11] http://en.wikipedia.org/wiki/Column_(database)
[12] http://www.w3schools.com/XML/xml_whatis.asp
[13] http://curinghealthcare.blogspot.com/2007/05/knowledge-standards-and-healthcare.html
[14] http://www.fiercehealthit.com/story/switch-icd-10-should-be-very-costly/2008-08-24?utm_medium=rss&utm_source=rss&cmp-id=OTC-RSS-FHI0
[15] http://curinghealthcare.blogspot.com/2008/11/personal-health-information-privacy.html
[16] http://healthfieldmedicare.suite101.com/article.cfm/symptoms
[17] http://wellness.wikispaces.com/Tactic+-+Research+Complementary+and+Alternative+Medicine+and+Human+Genetics+and+Genomics#CAM
[18] http://curinghealthcare.blogspot.com/2009/01/whole-person-approach-to-diabetes.html
[19] http://wellness.wikispaces.com/Tactic+-+Research+Complementary+and+Alternative+Medicine+and+Human+Genetics+and+Genomics#Genetics
[20] The ReAsure HealthNode™ system de-identifies consumers’ health data by “decompositing” their content files and extracting the data without identifying to whom it belongs. See http://cpsplit.typepad.com/cp_split_technology/2007/01/8_multicryption.html
[21] http://wellness.wikispaces.com/Tactic+-+Research+Complementary+and+Alternative+Medicine+and+Human+Genetics+and+Genomics
[22] http://wellness.wikispaces.com/Evidence-based+HealthCare+Decision+Support+System
[23] http://wellness.wikispaces.com/Tactic+-+Protect+Populations+with+Biosurveillance
[24] http://www.nhds.com/coms_agent911.html
[25] http://curinghealthcare.blogspot.com/2007/10/patient-centered-life-cycle-value-chain.html
[26] http://en.wikipedia.org/wiki/Single_Point_of_Failure
[27] http://www.readwriteweb.com/archives/google_failures_serious_time_t.php