Friday, May 19, 2017

These Are Some Thoughtful Pieces That Needs To Be Further Discussed And Considered.

These appeared last week.

What’s Digitization Doing to Health Care?

May 9 2017, 3:00am

New software is industrializing medicine by turning doctors into data entry clerks—and making them suicidally depressed in the process.

In more ways than one, medicine is dying.
A 2015 article in JAMA: The Journal of the American Medical Association suggests that almost a third of medical school graduates become clinically depressed upon beginning their residency training. That rate increases to almost half by the end of their first year.
Between 300 and 400 medical residents commit suicide annually, one of the highest rates of any profession, the equivalent of two average-sized medical school classes. Survey the programs of almost any medical conference and you'll find sessions dedicated to contending with physician depression, burnout, higher-than-average divorce rates, bankruptcy, and substance abuse.
At the risk of sounding unsympathetic, medicine should be difficult. No other profession requires such rigorous and lengthy training, such onerous and ongoing scrutiny, and the continuous self-interrogation that accompanies saving or failing to save lives.
But today's crisis of physician burnout is the outcome of more than just a job that's exceptionally difficult. The debate in Washington over the American Health Care Act to repeal and replace Obamacare, changing the degree of health coverage guaranteed to Americans, has monopolized our attention. But underneath, glacially slow changes to the way doctors deliver care are occurring. Medicine is undergoing an agonizing transformation that's both fundamental and unprecedented in its 2500-year history. What's at stake is nothing less than the terms of the contract between the profession and society.

The rise of the electronic medical record

An electronic medical record, or EMR, is not all that different from any other piece of record-keeping software. A health care provider uses an EMR to collect information about their patient, to describe their treatment, and to communicate with other providers. At times, the EMR might automatically alert the provider to a potential problem, such as a complex drug interaction. In its purest form, the EMR is a digital and interconnected version of the paper charts you see lining the shelves of doctors' offices.
And if that's all there were to it, a doctor using an EMR would be no more worrisome than an accountant switching out her paper ledger for Microsoft Excel. But underlying EMRs is an approach to organizing knowledge that is deeply antithetical to how doctors are trained to practice and to see themselves. When an EMR implementation team walks into a clinical environment, the result is roughly that of two alien races attempting to communicate across a cultural and linguistic divide.
When building a tool, a natural starting point for software developers is to identify the scope, parameters, and flow of information among its potential users. What kind of conversation will the software facilitate? What sort of work will be carried out?
This approach tends to standardize individual behavior. Software may enable the exchange of information, but it can only do so within the scope of predetermined words and actions. To accommodate the greatest number of people, software defines the range of possible choices and organizes them into decision trees.
Yet medicine is uniquely allergic to software's push toward standards. Healthcare terminology standards, such as the Systematized Nomenclature of Medicine (SNOMED), have been around since 1965. But the professional consensus required to determine how those terms should be used has been elusive.
This is partly because not all clinical concepts lend themselves to being measured objectively. For example, a patient's pulse can be counted, but "pain" cannot. Qualitative descriptions can be useful for their flexibility, but this same flexibility prevents individual decisions from being captured by even the best designed EMRs.
More acutely, medicine avoids settling on a shared language because of the degree to which it privileges intuition and autonomy as the best answer to navigating immense complexity. One estimate finds that a primary care doctor juggles 550 independent thoughts related to clinical decision-making on a given day. Though there are vast libraries of guidelines and research to draw on, medical education and regulations resist the urge to dictate behavior for fear of the many exceptions to the rule.
Over the last several years, governments, insurance companies, health plans, and patient groups have begun to push for greater transparency and accountability in healthcare. They see EMRs as the best way to track a doctor's decision-making and control for quality. But the EMR and the physician are so at odds that rather than increase efficiency—typically the appeal of digital tools—the EMR often decreases it, introducing reams of new administrative tasks and crowding out care. Many EMRs are designed to facilitate the job of billing before aiding in clinical decision-making. The result is a bureaucracy that puts controlling costs above quality and undervalues the clinical intuition around which medicine's professional identity has been constructed.
The EMR and the physician are so at odds that rather than increase efficiency—typically the appeal of digital tools—the EMR often decreases it.
Inputting information in the EMR can take up as much as two-thirds of a physician's workday. Physicians have a term for this: "work after clinic," referring to the countless hours they spend entering data into their EMR after seeing patients. The term is illuminating not only because it implies an increased workload, but also because it suggests that seeing patients doesn't feel like work in the way that data entry feels like work.
The EMR causes an excruciating disconnect: from other physicians, from patients, from one's clinical intuition, and possibly even from one's ability to adhere faithfully to the Hippocratic oath. If a link between physicians' computer use and suicide seems like a stretch, consider a recent paper by the American Medical Association and the RAND Corporation, which places the blame for declining physician health squarely at the feet of the EMR.
Drop-down menus and checkboxes not only turn doctors into well-paid data entry clerks. They also offend medical sensibility to its core by making the doctor aware of her place in an industrialized arrangement.
There is a great deal more here:
On a similar theme we also saw this last week:

Existing health IT is meant to help. Too bad it doesn't

The American Association of Family Physicians says that needs to change, and points to the kind of technology that actually enables better care.
May 09, 2017 11:29 AM
It’s a hard reality: Technologies that hospitals are using today do not adequately support the health of Americans, according to the American Association of Family Physicians.
“We believe that new types of information and new kinds of technology are needed,” AAFP wrote in the Annals of Family Medicine. “Technology has great potential to help foster connections and relationships among healthcare professionals, individuals, and communities, and to be a catalyst instead of the barrier it frequently is today.”
In the article, Vision for a Principled Redesign of Health Information Technology, the authors laid out a roadmap that they claimed should “form a national priority to close the gap in current health IT,” with expectations extending 10 years into the future.
The AAFP authors said in one year data visualization technologies will be central to care decisions, software will be capable of integrating patient-generated health data into EHRs, and new tools will emerge to better enable doctor-patient communications.
“We will see new technologies and new roles for technology that enable health system redesign and improvement, while supporting comprehensive payment models that focus on care delivery and health,” they said.
Looking ahead 3 years, the AAFP projected that transparent and actionable data will be widely available, including evidence-based medicine at the point of care. Technologies will also enable patients to engage in healthy behaviors and access their own medical records. And on the provider back-end, technology will drive more reliable learning within the health system.
More here:
The point here, that needs to be grasped, is that the place and use of EHRs is not settled and more work is need to really have them fit for purpose.
We clearly need EHR like applications to manage clinical information safely and predictably but just how that should work and just how they should be used is still emerging.
These articles, and many others, need to be considered and responded to in more depth than present has been the case.


Bernard Robertson-Dunn said...

Let me put on my systems engineering hat and make some obvious (to me) statements.

Industry and manufacturing involve highly defined, repeatable processes using physical materials. They are amenable to algorithms and automation.

Finance and retail involve highly defined, repeatable transactions concerned with intangible concepts such as money or a sale. They are amenable to algorithms and automation.

Healthcare is a social art. Its concepts, gathering of information, decision making and treatment are not highly defined, or involve relatively few repeatable processes. They are not amenable to algorithms and automation.

They are the real reason Health IT has failed. It's also why ADHA will fail, because they don't understand what I've just said.

I'll take my engineering hat off now.

Have a good weekend.

Trevor3130 said...

That "social art" (Bernard R-D) in medicine would have similarities in law and other professions where engagement with the client (or the suspect) is crucial to eliciting truthful responses and for knowing which question to ask next. So, do those other professions have as their centrepiece a screen and keyboard?

Bernard Robertson-Dunn said...

Trevor. Yes, but as a support function, not replacing decision making or automating processes to improve efficiencies.

Engineering is a prime example. Engineers use IT for a whole range of support functions; modelling physical processes, designing structures and systems etc.

What IT doesn't do is replace the fundamental engineering skills of innovation, analysis, creativity and problem solving.

And if there's one thing that medics do, it's problem solving of human ailments for which there is no simple, obvious, repeatable solution. Everyone is different and so everyone has a different set of problems and a different set of "target states". My stable (or even preferred) state is different from yours and from probably that of everyone else.

Much of current healthcare is symptom based. What is needed is a move to cause and effect. Medical science is nowhere near that yet. Healthcare data management must recognise this and be able to cope with it - i.e. solutions to health data management must be highly responsive and flexible as medical science changes.

Oliver Frank said...

Well said Bernard: "Healthcare is a social art. Its concepts, gathering of information, decision making and treatment are not highly defined, or involve relatively few repeatable processes. They are not amenable to algorithms and automation."

This is mostly true, but it is important to note that there are some repeatable processes in medicine that are amenable to algorithms and automation, especially in one of my major areas of interest, namely preventive care.

For example, we believe that all people over 65 years old should be offered and advised to have the influenza vaccine every autumn. To be a little more sophisticated about it, our record for every such person should clearly show whether we have offered the vaccine, and if not, why not. There can be valid reasons, such as if the person is terminally ill. Our record should also let us record in a structured way whether the person has refused to have the vaccine, and whether that refusal is temporary or permanent. Having this information in our record allows us to generate automated reminders as appropriate to the patient and the doctors, to try to make sure that we do offer the vaccine to all of our patients for whom we don't have a record of any contraindication or current refusal.

I would be interested in your thoughts about this.

Andrew McIntyre said...

Clinical decision support should be support and not decision making, it should make data available and present it in forms that make it easier to visualize and collate. Guidelines are just what they say they are, a guide and not a prescription, as we know that much of what we believe will turn out to be wrong. The bureaucracy does not get this and we see naive attempts to enforce guidelines and implement rigid pathways and protocols via eHealth rather than enabling the rapid acquisition and collation of high quality atomic data to enable better decision making by clinicians. Clinical messaging and data standards are vital to enable the transmission of clinical data to people who need it to make decisions. Its vital that that data be atomic so it can be collated and displayed/graphed etc. I used to hate the pile of paper results in random order that had to be manually processed with pencil and paper to make sense of the timeline. A huge collection of pdf results is just as bad, perhaps worse, as its likely that the volume of opaque low quality data will increase making it even harder to make sense of the past history of a patient. This is the danger of MyEHR, more low quality opaque data has the potential to make clinical care harder and not easier.

Anonymous said...

Having had conversations with some in the ADHA last year it seemed a conversation around Interoperability in the new age of information was about to commence at a national and inclusive level. This opportunity seems to have disappeared and I am unable to contact anyone at the ADHA? Personally the thinking and seemingly openness to discuss the subject in it entirety and a willingness (and indeed prime driver) to recast previous work against a changed landscape seemed one of the smartest things to come out of the ADHA.
The discussion I was hoping to have with ADHA and the community was discuss the fact that As healthcare becomes omnipresent, the contemporary paradigm of systems interoperability turns out to be incomplete and insufficient in attempt to address the complex interrelationships of diversified technical environment in which the clinical processes occur. While the traditional view of the healthcare systems architecture considered only clinical information systems and healthcare facilities, as the future Internet-of-Things becomes a reality, mobile devices, sensors, tags and other identifiable resources with communication and processing capability need to be taken in the picture. In such complex circumstances, the perception of interoperability needs to evolve from the consideration of interoperating pairs of systems to the capability of an autonomous system to sense, interpret, understand and act upon arbitrary messages received from a potentially unknown sender. In this sense, I had presented that interoperability becomes in fact a property of the system. Through ADHA I was looking to engage in open dialogue to explore and evolve the concept of interoperability in context of ubiquitous healthcare systems. Then, with a broad representation of the community define potential enabling factors for the interoperable systems involved in pervasive healthcare and assess the impact the Interoperability as a Property paradigm would have on the healthcare landscape and challenges.
Is there a place for this conversation and potential adoption in Australia? The ADHA seems to have distanced itself and the Standards bodies seem in an incubation state?

If the My Health Record is as it seems a now fixed solution in time, surely we should know be refocusing attention to the future and the enevitable replacement?

Anonymous said...

Interoperability and secure messaging are dead ducks. The MyHR will be used to exchange pdfs because that will give the impression it's being used. The ADHA exists only to run MyHR, not question its existence or to do real eHealth. Roll on the farce of a strategy to confirm our worst fears.

Anonymous said...

Yes agree, Tim has been tricked into delivering something no better than a 1990's style fax server service. The next 12 months will be a train crash worth watching. The opt outs solution to be delivered within a year? Being government it will take 3-4 times as long and cost 10 fold.

Yes agree the strategy is pointless now.

Anonymous said...

With these new cashable benefits emerging and the removal of patient outcome benefits, although the ADHA CEO mantra being all about patient dignity, it reminded me of an article from a few years ago -

Perhaps the Executive team at ADHA should be less selective in those they engage with.

My other concern is that yet again vendors will be forced more and more to build systems to meet Government needs and payment regimes than to make life for the patient and healthcare provider better.

Still I guess if you can't trust a bean counter who can you trust to do the right thing.

Bernard Robertson-Dunn said...

It's all about the money.

What's the data in MyHR that is most trustworthy?
a) patient identity data
b) MBS/PBS payment data.

Least trustworthy is healthcare data.

What is the most beneficial use of the data?

Under Section 70 para (1):
(a) the prevention, detection, investigation, prosecution or punishment of criminal offences, breaches of a law imposing a penalty or sanction or breaches of a prescribed law;
(b) the enforcement of laws relating to the confiscation of the proceeds of crime;
(c) the protection of the public revenue;
(d) the prevention, detection, investigation or remedying of seriously improper conduct or prescribed conduct;

i.e. tracking expenditure and looking for fraud.

IMHO, it's the only explanation for the government spending over $1.5b on a medically useless and privacy risky health data system. The priority is money, not healthcare.

Anonymous said...

Maybe they should rename it to myATO then, probably a good place to start looking.

But in all seriousness, it is what they are not putting the table that concerns me most, little things like the plan to replace NASH with the DTA authentication solution, there is so much dishonesty going on it is not funny

Bernard Robertson-Dunn said...

Re "the plan to replace NASH with the DTA authentication solution"

If you are talking about GovPass, then you need to be aware that Govpass isn't an authentication solution, it's a framework for authentication solutions.

The Australia Post product is an authentication solution:

Australia Post bolts digital ID service onto DTA platform
First step to public launch.
Allie Coyne
itNews Media Release Republication Service
May 19 2017

"Australia Post will tack its fledging Digital ID identity verification technology onto the Digital Transformation Agency-led Govpass digital identity framework to let users of government services easily verify themselves."

Having said that, I get the impression that DTA/PM&C are rather bemused by what Health/ADHA are doing. Where the meaning of the word bemused approaches a combination of "gob-smacked" and "disbelief"

Bernard Robertson-Dunn said...

Oliver, my apologies for getting your first name wrong.
Here's a repost.

re: "it is important to note that there are some repeatable processes in medicine that are amenable to algorithms and automation, especially in one of my major areas of interest, namely preventive care."

Yes there are many repeatable processes (and, as Andrew says, rules and guidelines) in healthcare. But as you point out many of them are conditional, e.g.

"all people over 65 years old should be offered and advised to have the influenza vaccine every autumn" except when .....

With healthcare, the big problem is in identifying which standard processes to implement and when as well as when not to.

IMHO, the problem arises for several reasons:

1. The human body is an incredibly complex set of interacting systems with no definitive design. People react differently to their surroundings and to treatment. There is no one size fits all.

2. There is a great reliance on symptoms and health history, as reported by the patient. As Dr House said, All patients lie. This is probably not totally true but I doubt that patients tell the complete truth in the sense that they report everything about their health status. i.e they lie by omission, often thinking something is not important.

And also IMHO, as Andrew pointed out, the MyHR has (or might have) a whole lot of useless and un-managed information. It also lacks a full set of patient health data as I've outlined elsewhere i.e. environmental and behavioural data.

Dr Ian Colclough said...

Oliver (@7:43 AM) ... said "Having this information in our record allows us to generate automated reminders as appropriate to the patient and the doctors, to try to make sure that we do offer the vaccine to all of our patients for whom we don't have a record of any contraindication or current refusal."

Surely, in today's medical practice systems, recalls and automated reminders are a fundamental function of any practice system! They actually generate revenue! They were first introduced in the systems designed in the early 1980's.

Is there a need (and can one justify the cost) for the MyHR to usurp this well worn function and duplicate what medical practices routinely do today?

Anonymous said...

Does MyHR do anything that other systems don't already do, and do better?