Day 5 started off early again with a talk by Tonya Hongsermeier on Complex Adaptive Systems. A Complex Adaptive System
is made up of a large number of self-organizing independent agents that seek to maximize their own goals but operate according to rules and incentives in the context of relationships with other independent agents. She provided a god set of examples of the transition from linear through complicated to complex in healthcare. Linear is ordering a test, complicated would be doing a simple colonoscopy in a low risk patient, and complex would be managing a septic patient. The issue arises on how to get people to understand they are in a complex adaptive organisation and how to manage the relationship, and utilising the technology to remove some of the complexity where possible. An interesting thing was the healthcare modified data information knowledge wisdom pyramid, where the knowledge starts as know about to know how. The role of good decision support is to provide the most likely solution as the easiest option to select. However this logic is not linear.
The next speaker was Roberto Rocha on Translating Knowledge into Practice for Continuous Improvement. Improvement requires complex CDS, it’s not the simple stuff that is causing the problems, however the deployment needs to be simple.
The goal is science-driven health care or a learning healthcare system to enable moving from reference to action and ultimately to executing
After the break Kenneth Mandl spoke on HIT Architectures for Health Care: Innovation and Transformation. Ken is from the Children’s Hospital in Boston which has done some very innovative things, including Indivo, the basis for many personal health record systems including Dossia. He spoke of the need for a Learning Healthcare System as the goal for health informatics. He spoke of the App Store for Health concept and the need for user interface development and allow people to choose the interface that works for them. Rather than just interoperability he suggests substitutability should be the next stage. They even have set up a Smart App challenge. He went on to talk about how the Personal Health Record may be the disruptive innovation and compared it to the current HIE models, which have been unsuccessful. He commented on the Australian PCEHR project as a very positive step, and whilst it faces some technological and sociological challenges, it does move us forward. A great example of linking the PHR to online disease specific social networking sites, in this case tudiabetes.org showed that people were keen to share their information and also enter their data.
The next session was on the governance of clinical decision support. Governance leads to a common vision, coordination and transparency, and provide the organisation the ability to manage expectations and be agile enough to respond to unanticipated demands. Within Partners, which is a collection of world leading providers, which raises its own governance issues, he described the journey of getting to a stable governance model and the various issues involved, which led to much discussion. He was followed by Dr Goldberg who discussed how CDS is integrated with EHRs. He described the various currently available CDS tools, and how they affect the systems they are running on. Some early results from the use of Smart Forms which combine CDS logic with user interface design and prompting of behaviour have been shown to be very beneficial.
The day was wrapped up by Blackford Middleton looking at why we need leadership in health IT. The provider’s dilemma is that we still hurt people while delivering healthcare, and the variation in healthcare remains huge. The question of how HIT saves money, and it essentially comes from improved effectiveness, reduced duplication, taking away reworked, be they test or administrative tasks. The improved quality of care decreases the costs associated with adverse events. Data sharing reduces redundancy and associated labour costs, telehealth reduces costs, and the PHR improved admin efficiencies. He went through the masses of data available, much of it from work at Harvard. From the purchaser’s perspective, the rapid growth in costs with 25% of the cost being administrative costs. The evidence for CDS is great in places where it is done well; the challenge is how to scale it out to the rest of the country, if not the world. We need to research more completely what we need to do, where CDS can intersect with HIT usage.
The wrap up discussion pointed to the differences and similarities between the US experience and mine in Australia and others from Canada. We all recognise the issues of cost, but we also recognise that the value of clinical expertise needs to be supported. There was much discussion of where to next, and what else we need to cover. Telemedicine came up as did personal health records, so it seems Australia is heading in the right direction.
Overall it was great session, very informative and the faculty were very helpful. A special mention for Blackford Middleton who went out of his way to be inclusive, was full of knowledge, and showed great interest in what is happening around the world. It would be great to get this course delivered down under for our health folk to understand what is needed to make ehealth happen. They emphasised it is a journey, and they need to persevere.