Tuesday, December 28, 2010

Finale: Drinking Safely and Healthily from Liquid Information

Happy New Year! If you must drink, do it responsibly and safely. Which brings us to the subject of this Finale to a blog series that started here. How can Health IT systems help clinicians to consume/drink the liquid information that will increasingly flow to them? How can these systems help users protect both patient safety and clinician productivity?

The faucet has been opened. It’s fairly easy to tell developers to send clinical information to others. It’s harder to know what to tell providers to do with what they receive. The trickle of information exchange hasn’t become a flood yet, but let’s be prepared! Clinicians want the information to be usable, not a hindrance. They want to do the right thing, but they can’t afford to reduce their capacity to see patients, and they don’t want to be liable for negligence if they can’t read every word of every available electronic record for the patient. Policies and guidelines for realistic expectations and duties of clinicians to retrieve and read electronic information would be very helpful coming from medical, legal, and health information management professional associations.

Patient safety is impacted both if there’s inadequate information flow but also if there’s too much. We’ve heard of “alert fatigue” in clinical systems, and could face “information overload fatigue” too, where important information is obscured by “noise” that could lead to errors or duplication as occur in the absence of information flow. While the PCAST report on health information technology proposes applying search technology (good idea), that may be helpful but insufficient. I can “Google” anything, but how often do you or I look beyond the first page of results, even when there are thousands of hits? I implicitly rely upon the search engine to display the most relevant links first, since my time is limited. While a patient’s medical records are much less voluminous than data in web searches, even dealing with only 24 clinical documents per my personal health example requires indicators of relevance to aid decision making. If I don’t look at Google search results page 2, it’s probably not a big deal, but the stakes are much higher for patient care: who can decide what’s most important to show for a clinical encounter, especially since that varies depending on the encounter’s purpose?

Thankfully, healthcare and academic organizations realize the need to tackle this challenge. I was fascinated by the findings from this medication reconciliation project at Partners Healthcare: “design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list.” It was pioneering work at the time, and was a springboard for further research, such as refined aggregation algorithms based on more standardized data, and clinician-vetted UI techniques to reduce cognitive burden and add value.

In 2008 when I helped interoperability and ambulatory workgroups (including physicians, nurses, pharmacists, engineers, and others) write the CCHIT certification criteria and roadmap through 2011, we proposed 2009 as a first step in consumption of discrete data such as medications and allergies from C32 CCDs, but concluded that we shouldn’t be prescriptive about EHR functionality or workflow to handle such data.

Medications are just one example of data that needs to be reconciled after being exchanged. A new clinical data Reconciliation project at IHE offers promise to advance the cause of clinical decision support for reconciling problems, allergies, medications, and more. It’s humbling to acknowledge that HIT isn’t so sophisticated or trusted to make clinical decisions, any more than web search can buy your next car automatically. Instead, we should share the results of research to inform and stimulate innovations that are then tested in multiple care settings, before even thinking about regulating and standardizing functionality. But I’m all for specifying how standardized information exchanges can be inputs to these innovative algorithms and UIs.

To return to my musical analogy, music isn’t just playing the notes in a score: but rather how the score is brought to life to touch the heart through the genius of great performers. We shouldn’t try to turn musicians into robots where every nuance is pre-programmed. Similarly, in HIT MUsic, there’s room for the art as well as the science!

If anyone reading this can point to interesting research and experiences regarding consuming health information that’s exchanged, I’d love to hear about them. The results would benefit providers and developers EHRs and HIEs as well.

1 comment:

  1. David,

    This has been a terrific symphony and is clearly very topical with expectations from meaningful use and PCAST for growing exchange of structured and computable health data. It is critical that we understood provider needs and constraints to avoid a negative response to the availability of more and more timely patient data.