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Bill Stead on the National Research Council’s Report

January 12, 2009 News 5 Comments

Full text of the report is available here.

The report calls for a change in approach to health care IT.

This conclusion does not reflect negatively on the sites visited. To the contrary, their pioneering work and suggestions let the committee see the way forward. It does not contradict calls for increased investment in health care IT. Better management and use of information are essential to improving the health care system.

The report suggests that a larger dose of today’s health care IT will result in both improvement and harm. It will cost more and take longer than people expect. Collectively, the result will fall far short of what is needed.

For example, today’s clinical applications tend to be monolithic and complex. Rather than enabling small improvements in practice, the many information system interdependencies actually slow down improvement! Instead, clinical applications should reduce barriers to clinicians and patients doing what is best for care – even if doing what is best requires rapid cycle, iterative change in clinical behaviors and work flows.

A different outcome is possible. We do not need to wait for better IT before we move aggressively forward. However, near-term success will require a fresh approach to managing the investment by health care organizations, our health care IT vendors, and the government.

The report lays out five principles for use of IT to support evolutionary change in health care that are actionable in the near term. With a longer view, it identifies four principles to support revolutionary change and several research challenge problems.

It includes six recommendations directed at the senior management of health care organizations and, through them, to their vendors. Let me highlight a couple.

Organize incentives, roles, workflow process and supporting infrastructure to encourage, support and respond to opportunities for clinical performance gains.

In other words, the IT infrastructure should evolve with the improvement process, not lead it.

For example, if your goal is to reduce medication administration errors, start with incentives and infrastructure for blame-free reporting. Next, identify the situations with a high rate of "wrong patient, wrong dose" errors. Then, target deployment of technology support like bar code medication administration to those situations. Finally, continue to monitor performance, refining the combination of process and technology if needed, or extending to the next highest problem area.

In this way, you guarantee improvement. Use the technology only where needed and correct unintended consequences early.

Balance the institution’s IT portfolio among the four domains of automation, connectivity, decision support, and data mining capabilities.

The majority of today’s health care IT is designed to support automation, with some investment in supporting connectivity and little support of decision making or data mining. Yet the IOM’s vision for 21st century health care expects support for cognitive activities (helping providers and patients think about complex choices as they make decisions) and a learning health care system (mining related bodies of data to recognize and respond to patterns).

These activities are much more about connectivity, decision support, and data mining than about automation. The required shift in focus is large. Technology exists to support movement in these directions, but it is outside the comfort zone of many health care organizations and the established health care IT vendors.

Finally, read the report! It is short. It reflects careful study and review. With complex issues, one sentence may balance another. Hearing one sound bite without the others can mislead.

Health care organizations and health care IT vendors should read section 3 (rebalancing the portfolio), section 4 (principles for success), and section 6.3 (recommendations for health care organizations. They add up to only 12 pages.

In addition, I would point vendors to Appendix C, which summarizes the committee’s observations, the consequences, and opportunities for action, with the latter tagged as short term or research. Check your current offering and product direction against the ones tagged as short term.


William W. Stead, MD is associate vice chancellor for strategy/transformation, director of the Informatics Center (which includes the Department of Biomedical Informatics of the School of Medicine, the Eskind Biomedical Library, and the Center for Better Health), and CIO at Vanderbilt University Medical Center; and chief information architect for Vanderbilt University. He is chair of the Committee on Engaging the Computer Science Research Community in Health Care Informatics, which produced Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions under the auspices of the National Research Council.

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Currently there are "5 comments" on this Article:

  1. I suggest the committee take a close look at the NHS in the UK, and the minimal success achieved there. There is much to learn from their experience.

  2. I am not surprised to see the results of the IOM study. I could not agree with them more.
    I have been in the health care IT profession for over thirty years and although progress has been made over those years, IT in healthcare is still viewed as a transaction /data system, not an intelligent system to support clinical or administrative workflow. For forty years we have invested billions of dollars in capturing, storing, aggregating and reporting transactional data. We, as an industry are data rich, and information poor.

    So why is it that way? Why don’t we have more ‘smart’ process oriented tools /systems instead of an oceans of data on incomprehensible reports? Here’s my assessment:

    1) It is significantly less for a for a vendor to build data transaction systems, than process support systems. They could burn through billions of dollars building a real process oriented system and never see a ROI.
    2) Building data systems that can support and improve clinical or administrative processes is very complex and very time consuming.
    3) Process systems and clinical protocols can vary significantly from facility to facility. Whether that is good or bad is separate debate, but that is the way it is still today.
    4) Clinical protocols are dynamic, medicine is not a stagnant science, and what we don’t know can fill the universe. We learn something new every day, and we adapt it by changing the protocol. So an automated process system would have to change with it ­ …over and over.

    Some of these same challenges exist outside of healthcare in other industries. Many sophisticated tools have been developed to address process variability. We should look at applying as many as we can. It’s time we started doing something with all that ‘data’.

    Frank Poggio
    The Kelzon Group
    Barrington, IL

  3. Great report.

    Looks as if it might explain alot – for example, have physicians been reluctant purchasers or Saavy consumers – Looks like Physicians are Saavy consumers holding on buying expensive EMR systems with little proof of efficacy.

    Simple programs, designed to improve care work. It’s possible to spend less than $100 / month / physician and improve metrics of care from 40% to 80% within a three or four month period.

    The secret is the right information in the point of care workflow; performance monitoring and safety-net lists of patients falling through the cracks – in other words, communication and knowledge within workflow – whether a paper or electornic office.

    Congrats to the NRC team for a terrific report highlighting the emperor’s clothes in the HIT world. Hopefully application of the economic stimulus funds from the federal government will follow the path illuminated by the NRC report.

    John Haughton MD, MS

  4. Bill is just rationalizing his history. 10 years to implement? Maybe at Vandy, if you try to build it on your own from scratch. Not in most of the rest of the free world though. Bash vendors all you want Bill, but don’t project your failures on an entire industry.

  5. I agree with your conclusions. There is far more at stake than what you state which I’ve discussed here: http://linuxmednews.com/1236661936/index_html The thing missing is a mechanism for the flexibility you describe. The government appears poised to double down on allowing federal funds to pay for proprietary EMR black box software, greatly reducing the needed flexibility and field serviceability that you describe. It is a throwback to alchemy in which techniques were kept secret for turning lead into gold in order to corner the market. The side effect was that everyone had to discover on their own that mercury is poisonous. I have called for a law allowing federal purchasing funds to only be used for Affero General Public Licensed software. So far I am meeting much resistance but it is the only way that such flexibility and performance can be assured. — IV

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