The Data Life Cycle

This year and most of next will likely be spent figuring out how to get EHR systems installed in hospitals and physician offices. Most of the organizations making this transition will be doing so as a reaction to the federal government’s incentives and penalties for not doing so. But there is a much bigger, long-range picture that should provide a framework useful to healthcare leaders. The meaningful use rules require providers to report quality measures to various agencies for analysis. Some of this will be used to determine whether or not the system is being used at all in order to manage incentive payments, especially in the beginning. Other data, some not even conceived of yet, can be used to help improve what we know about medicine and to develop best prevention and treatment practices. This diagram shows one way to look at the process (click to enlarge).

From "data" to "knowledge"

Today, at least in the US, we’re in the first quadrant in the lower left corner. Here, we are just entering the first round of data collection on a national level. In the next quadrant, data will be aggregated and studied for various purposes. Early on, the type of data collected will help determine compliance with meaningful use, and other quality reporting initiatives. In quadrants 1 and 2, it’s still data, or at best “information,” while quadrants 3 and 4 represent the process of learning from that information and then finding ways to transfer that knowledge into support systems that can improve point of care quality and value to both the patient and the healthcare system.

The interesting questions that must be addressed in order to accomplish this are at the heart of “The Art of Medicine and Technology,” and what we want to explore on this site. Some questions arise at each point along the cycle:

Quadrant 1:

  • What kind of data must we collect at this point in order to add value in Quadrant 4?
  • Are we collecting it now?
  • Will it require re-engineering systems?

Quadrant 2:

  • Who does this work?
  • Who has access to the data?
  • How do we ensure that the analysis is unbiased and adds to the art of medicine?
  • Are there any ethical issues involved in doing mass aggregation and analysis of health data?

Quadrant 3:

  • What do we want to learn?
  • Can technology help us uncover unanticipated discoveries?

Quadrant 4:

  • How will this knowledge translate to support systems?
  • Can we trust what we do?
  • Is it ethical to transfer knowledge “in progress” to computerized systems?
  • How many cycles are required before physicians move from trust to reliance on technology?

As always, your comments are welcomed!

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Advance Directives and EHRs

The recently unveiled final rules for meaningful use of electronic health records in the United States include as one of the objectives: “Record whether a patient 65 years old or older has an advanced directive as structured data.” It is included as one of the optional “menu set” of objectives and therefore not required as are the objectives found in the “core set.” Advance directives had been in the original, recommended set of objectives from the policy committee, which was created as part of the American Recovery and Reinvestment Act (ARRA) to advise the Centers for Medicare and Medicaid Services (CMS) on how to go about the business of determining whether or not a physician or hospital had become a “meaningful user” of technology. When the proposed rule came out earlier this year, the policy committee’s recommended objective had been eliminated. Now with the final rules, it’s back in, which is a good sign.

What’s interesting is some of the thinking behind this particular objective and how it reflects the way we approach the application of technology to our stated goals. In its discussion of the rules objectives, CMS says:

… a restriction to a more at risk population is appropriate for this measure. By restricting the population to those 65 years old and older, we believe we focus this objective appropriately on a population likely to most benefit from compliance with this objective and its measure.

Okay, let’s accept the assumption that people over 65 are statistically more likely to encounter the type of health issue that would require referencing an advance directive. Knowing that the patient has an advance directive, and noting it in the EHR,  helps the doctors and the institution make better decisions, but only up to a point. The rule does not require that systems store the content of the advance directive, so in an emergent situation, vital facts are missing. CMS says it did not require the content of the advance directive to be held in the EHR because there may be conflicting state regulations about such things. Fair enough.

But by limiting this measure to patients over 65, the rule implies that there is less benefit to younger patients. If Terri Schiavo had had an advance directive, the seven year ordeal over whether or not she should have feeding tubes removed would have been avoided. Resolving her case was costly in both monetary and emotional respects, to her family, the community, and the country. What then, is the real “risk” CMS notes in the rules? It is more complex than the risk of contracting an illness if you are over 65. When talking about advance directives, there are three dimensions to risk:

  1. Risk to the patient. Yes, older patients are more at risk to have a life threatening health issue. But by not having an advance directive, the patient risks loss of personal dignity and control over how these sensitive decisions are handled;
  2. Risk to the institution. This can be summed up as: Lawsuits, Cost, Reputation;
  3. Risk to the community. Whether it is a small town or the entire country, end-of-life care is a difficult discussion with a huge emotional component. Issues of faith, agenda and politics are brought into full view. An advance directive can keep a personal decision from becoming a public debate.

Right now the advance directive objective will only apply to hospitals and critical access hospitals (CAH). The rule will not apply to physicians because, as CMS notes:

…we believe many EPs [eligible professionals] would not record this information under current standards of practice. Dentists, pediatricians, optometrists, chiropractors, dermatologists and radiologists are just a few examples of EPs who would only require information about a patient’s advance directive in rare circumstances.

That makes sense, but by excluding eligible professionals as a class, primary care physicians are also excluded from playing a role in meeting a broader objective of having more Americans make thoughtful decisions about end-of-life care. And primary care encounters are the most logical place for these discussions and for entry into the electronic record. Instead of excluding all EPs, primary care should be included, while specialties should be excluded. Part of the problem here is that the HITECH act attempts to lump providers into broad categories of hospitals and physicians. Technology is simply “certified EHR” technology, with little allowance for the many variants already out there.

Finally, if we want pervasive changes in the system, specific to advance directives, the standard of practice must change. Physicians, especially those offering primary care, could drive this change by asking the question of all patients: “Do you have an advance directive?” Either way, the answer is recorded in the EHR, and the meaningful use requirement is fulfilled. In the short term, this benefits the institution, since it may qualify for incentives. In the long-term, it raises awareness among the general public that this is something to think about now, hopefully long before reaching the age of 65. Smart EHR vendors will include this in their systems now whether they are designed for ambulatory or inpatient care. “Meaningful use” has broader implications beyond qualifying for incentives, and this is one of them.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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From Trust to Reliance

Yesterday I noted how deeply the concept of trust is intertwined into everything we do in healthcare. It really creates a web of interdependent individuals, organizations and systems, each of which must trust that the other is effectively carrying out its role in the overall delivery of healthcare. Now the Leapfrog Group has issued a report summarizing the results of its computerized provider order entry (CPOE) evaluation tool. The data gathered between 2008 and 2010 will be of interest to anyone wondering whether CPOE should be included in the first level of meaningful use. According to the report, over 200 hospitals tested their CPOE systems to see if they caught common medication errors, including those that could be fatal. On average, the systems missed about one-half of the routine medication orders and a third of the potential fatal orders.

Leapfrog recommends testing and monitoring for all technology adoption, and that best practices are shared more transparently. “Competition is healthy, but in the case of IT adoption, collaboration is far better” the group notes. The group further recommends more implementation of CPOE, which can, when set up correctly, reduce medication errors. Fair enough. And now some questions:

  • How do we determine the best practice? Are there “flavors” of best practice for different demographics?
  • How can that best practice be represented and supported by our technologies in an efficient way?
  • How can we keep it current?
  • How do we begin moving from “having CPOE is good” to “having good CPOE is better”?
  • How can we integrate and begin to depend upon technology that is still evolving while maintaining quality in a high-risk, high-stakes environment?
  • Is it ethical to use technology to support patient encounters when we know the technology is still in its infancy?

The last two questions are most interesting, and probably the most challenging. On one hand, we are trying to create technical support systems that can reduce risk and alleviate some of the burden by transferring some of our knowledge responsibilities to the technology. On the other hand, we add to the risk and the burden because we must ensure that this technology mentoring process does not result in lower quality care, or deaths. In short, how do we know when it’s okay to begin trusting our systems? And coming to trust our technology is not the same as coming to rely on technology. Trust is a forerunner to reliance, and it holds true for the patient – physician relationship too.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Two kinds of thinking

Certification Rules Are In

A nice range of things to consider over the weekend: first, the final rules for the temporary electronic health record (EHR) certification program were released. If you’re reading from outside the US, this is just one piece of the giant puzzle currently being assembled here to push physicians and hospitals closer to the use of EHRs. Several years ago, the government decided that by certifying that EHR systems could do what was promised, some level of risk would be removed, and physicians would begin to adopt these systems more rapidly. Now, in order to receive financial incentives and to avoid penalties, physicians and hospitals that participate in Medicare and Medicaid programs must adopt EHRs that have been certified. With the new laws, the meaning of certification has shifted. Instead of a form of consumer support, certification is as much a required attribute of the software as whether or not it can manage various types of clinical documentation or report quality measures. Previous certifications done by the Certification Commission for Health Information Technology (CCHIT) will not be grandfathered into the new system. Instead, organizations that wish to do the business of certifying EHR systems must apply to become a certification body. This includes CCHIT.

Incentives for meaningful use of EHR systems become effective October 1, 2010 for hospitals and January 1, 2011 for physicians. Between now and then, new organizations must be deemed capable of certifying EHRs, the systems must be certified, and previously certified systems must be re-certified. The current focus in the US regarding medicine and technology centers around, and will continue for a few years to be centered around, achieving meaningful use and avoiding penalties. Meaningful use will not be determined based on how creatively a hospital or physician is applying technology for the benefit of the patient or the community. It will be determined by meeting the requirements spelled out in a checklist of functions and features. Call this “No EHR Left Behind,” as the medical community scrambles to “pass the test.”

By the way, CMS has a new site that organizes all of its EHR incentives-related activities. Find it here:

Artificial Intelligence

At another end of the spectrum, the cover feature in the New York Times Magazine Sunday asked: “Who is Watson?” This I.B.M. project created a computer that is designed to think like a Jeopardy contestant and can, on one hand, appear incredibly intelligent. On the other hand, it can completely miss the mark, which is easy to do considering the range of wordplay the game entails. It’s interesting reading, even provocative at times. It’s especially provocative when John Kelly, head of I.B.M.’s research labs says he wants to create “a medical version” of the computer for use in hospital emergency departments. Armed with what would amount to every medical paper ever written, the computer would be able to come up with rapid-fire answers to help doctors make decisions.

Cool idea, but how we get there is more complicated than that, and raises a few questions. For example:

• At what point does research become fact or “knowledge”?

• What process determines which research becomes part of the computer’s knowledge base?

• What is the “peer review” process for new ideas generated by a computing system?

• Is it ethical to ignore patient narrative solely in favor of clinical fact?

• What power will a physician retain to overrule, modify or concur?

“The problem right now is the procedure, the new procedures, the new medicines, and new capability is being generated faster than physicians can absorb on the front lines and it can be deployed,” says Kelly. This might not be the best reason to employ technology. Simply having “everything” in a database does not mean you have information. There is a fine line between using technology to distribute information we know to be helpful, and allowing technology to make those decisions for us. With the former, we remain accountable to patients and society; with the latter, we abdicate responsibility. Somewhere in the middle lies the art of medicine and technology.

The NYT article is here:

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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