"Essential to healthcare reform are two elements: standards of care for managing clinical information (analogous to accounting standards for managing financial information), and electronic tools designed to implement those standards. Both elements are external to the physician's mind. Although in large part already developed, these elements are virtually absent from healthcare. Without these elements, the physician continues to be relied upon as a repository of knowledge and a vehicle for information processing. The resulting disorder blocks health information technology from realizing its enormous potential, and deprives healthcare reform of an essential foundation." — Lawrence Weed, MD
The foregoing quotation by the father of the problem-oriented medical record and a widely respected medical researcher, practitioner, healthcare critic and healthcare information technology advocate since the 1960s, summarizes the current situation of human medicine, as manifest in private practice and in hospitals and other healthcare delivery organizational environments.
The clinical cognitive conundrum
Medical education and professional practice traditionally have been predicated on individual practitioner memory and cognitive capabilities for accrual and application of knowledge and expertise. This approach not only impedes collaborative consultation and team treatment but also interrupts the regular accrual and ready accessibility of medical knowledge in general: There is just too much new information to remember, let alone, apply it.
Physicians are expected to learn and accumulate a large volume and variety of medical information, as well as apply it during the plethora of concurrent processes that typify medical practice. All of these circumstances combine to create the "clinical cognitive conundrum" — the inability of the clinician to perform complete, accurate and timely information acquisition, absorption, analysis and application in spite of the typically ready availability of most information and medical resources, owing to functional limitations of the human brain and the pressures of time.
The clinical cognitive conundrum leads to several negative results, principal among which is the persistence of an unacceptable number of medical errors in modern medicine and the consequent increase in patient morbidity and mortality. In fact, the number of preventable patient deaths in United States hospitals is roughly equivalent to that of four full jumbo jet crashes weekly with no survivors! As with commercial aviation accidents leading to passenger injury or death, even one occurrence of nosocomial or iatrogenic pathology or medical error leading to increased severity of illness or death should be unacceptable. However, these errors and accidental deaths continue to be tolerated by healthcare providers and tacitly by their patients. The positive transformation of medical practice and healthcare delivery can be effected in large measure by providing real-time cognitive support to clinicians, administrators and other healthcare provider subject matter experts in the form of an Internet-based (a.k.a. a "cloud"-based) IT solution.
IT mitigation of the cognitive conundrum
IT can be used to mitigate the clinical cognitive conundrum, but to be effective it must include the following characteristics or element:
- Accessible via the Internet using any stationary or mobile digital device with minimal cost and complexity;
- Include features for the design and deployment of automated administrative and clinical processes;
- Capable of choreographing staff with IT systems and digital devices and data sources in a common workflow for specific purposes,;
- Run continuously with capability for state management over extended periods of time (e.g., the "womb to tomb" existence of a patient):
- Include features and functions for real-time event detection and time-related analysis, dynamic database access, and Boolean and Bayesian decision-making and predictive analytics; and
- Capable of "pushing" information and action requests to choreographed designated actors so as to provoke execution of defined tasks.
- Low-cost solution, such as a software suite in the software-as-a-service mode charging a monthly subscription rate
An IT solution with the above capabilities would likely lead to a significant reduction of medical errors and improvement in patient safety and clinical outcomes (including diagnosis and treatment). In addition, unlike traditional quality improvement methods, the prescribed IT solution does not exacerbate the clinical cognitive conundrum; because it automates the results of procedure analysis and optimization, and thereby minimizes the need for memorization and circumstantial recall of new or revised procedures for current application.
Prescribed IT solution scope and application
How can or should the prescribed IT solution be applied to mitigate the clinical cognitive conundrum and, thereby, to improve significantly healthcare provider practices and subsequent case outcomes and administrative operations and results? The prescribed IT solution can address four generic healthcare and medical use cases as detailed below:
1. Personal health management (applicable to a healthy or "walking wounded" individual)
Given the nature of the object of health management – the human body in its state of homeostasis (i.e. – continuous biochemical autonomic adjustment to maintain a steady and healthy state of bodily systems and the human body as a whole), the management of an individual health of a person (not necessarily a patient) requires constant monitoring and assessment of as many physiological and psychological signs and symptoms as possible during the life-long (i.e. – womb to tomb) existence. This monitoring and assessment, made accomplished in part by comparison with specified parameter value thresholds and previous point-in-time values and/or individual norms that are constantly calculated, is accomplished by the prescribed IT solution using such techniques as "state management" and "long-running tasks" that are not practicable and/or are impossible for human minds individually or collectively to execute without interruption or fluctuation in completeness, accuracy and timeliness.
2. Medical practice support (applicable to a person with perceived pathology that engages in an episode of out-patient or in-patient care with a professional practice or institutional healthcare provider)
The personal health management features/functions detailed in item 1, above, are continued; and the accrued information is leveraged by the healthcare provider to provide input to medical practice activities including diagnosis, diagnostic and therapeutic testing and other procedure determination, treatment planning, care monitoring, discharge planning and determination, and post-discharge monitoring (essentially a return to the item 1 use case). Also known as "clinical decision support," the automated event evaluation, decision management and similarity and predictive analytic capabilities of the prescribed IT solution make feasible the automation of the differential diagnosis, which typically is a list of about ten diagnostic possibilities determined by the data points derived from the patient's medical history and physical examination to which the diagnostician's experience and powers of recall are applied. The prescribed IT solution avoids virtually all of the cognitive shortcomings to which a physician's diagnoses are subject by avoiding bias, applying predetermined rules and decisions established a priori by qualified clinicians collaboratively and leveraging evidence-based database from which statistically determined similar cases are extracted and analyzed.
3. Healthcare delivery operations (applicable to the plethora of administrative and clinical processes demonstrated in healthcare delivery organizations as defined and/or standardized by such accrediting organizations as The Joint Commission (USA) and Accreditation Canada)
The personal health management and medical practice support features/functions detailed in items 1 and 2, above, are continued; and the accrued information and previously instantiated automated processes are continued electively in the broader context of organization (typically hospital) operating standards and practices. Therefore, they continue to operate in conjunction with other processes instantiated by the provider organization to manage the patient/case from admission to discharge and also to manage organization-/facility-specific operations ranging from alert fatigue prevention in the intensive care units, surgical checklist prevention of invasive procedure medical errors to maintenance of equipment and supplies to ensure continuous good working order and to prevent nosocomial infection and other nosocomial or iatrogenic illness.
4. Medical common-body-of-knowledge accrual (applicable to all of the three foregoing use cases)
This use case puts the icing on the medical/healthcare knowledge accrual and archiving cake by merging clinical experience automatically with the medical common body of knowledge in real time, thus fulfilling the recommendations of learned healthcare business scholars and rendering knowledge accrued in the resolution of a given case available for application in the next-occurring similar case. This capability enables actually most productive approach to the complexity of human medicine and case management – an approach that accommodates managing constant change, favoring Bayesian (multi-variate) over Boolean (logical decision tree) logic, recognizing individual patients/cases as "cohorts of one," managing analogue objects digitally, and facilitating stochastic optimization in medical problem resolution and practice execution without additional and unrealistic burdening of clinician cognition and threatening of patient safety.
Pete Melrose is a solution-oriented healthcare information technology professional and innovative leader, who achieved notable success prior to joining IBM in 2005 by directing a broad range of private and public sector corporate IT initiatives while participating in and publishing about many thought leadership and solution innovation projects. During a career beginning in 1967, Mr. Melrose has worked as an informatics researcher, business analyst and auditor, software developer, IT manager and CIO at private- and public-sector health and human services enterprises, product and project manager at independent software vendor firms, and healthcare IT and HIPAA consultant. Currently he is President and CEO of CHARTSaaS.org, the nonprofit creator of the Cloud Healthcare Appliance Real-Time solution as a service.
Allan Somerville Brown is a self-employed consultant who works with clients to solve integration challenges. Prior to this, he served as director and managing partner for the North American region of Primeur USA. Before his time at Primeur, he worked at IBM for 40 years.
Kevin McLaughlin has 23 years executive leadership of sales-driven companies in various industries, including healthcare. He has also taught graduate-level healthcare finance for 20 years.