How Do We Build Health 2.0 Into the Delivery System?

The Health 2.0 Meets Ix conference, will take place April 22 and 23 in Boston, Massachusetts. As part of the lead-up to the conference, which will focus on the interplay between the Health 2.0 and Information Therapy (Ix) movements, the THCB, the Health Affairs Blog and other participating blogs will feature a series of posts discussing ideas that will be featured at the conference.

The post below by John Halamka is the second in this series. The first post in the series described the background and main themes of the Health 2.0 and Ix movements. In his post, Halamka offers a vision on how best to build Health 2.0 into the health care delivery system; he will participate in a debate on this topic in Boston. Halamka also recently contributed to a Health Affairs online package on implementing the health information technology provisions of the recently passed economic stimulus legislation. The package was published in conjunction with the Health Affairs March-April issue on health IT.

Over the past few months, I’ve seen a convergence of emerging ideas that suggest a new path forward for decision support and information therapy. I believe we need Decision Support Service Providers (DSSP), offering remotely hosted, low cost knowledge services to support the increasing need for evidence-based clinical decision making.

Beth Israel Deaconess has traditionally bought and built its applications. Our decision support strategy will also be a combination of building and buying. However, it’s important to note that creating and maintaining your own decision support rules requires significant staff resources, governance, accountability, and consistency. Our Pharmacy and Therapeutics Committee recently examined all the issues involved in maintaining our own decision support rules and it’s an extensive amount of work. We use First Data Bank as a foundation for medication safety rules. We use Anvita Health to provide radiology ordering guidelines based on American College of Radiology rules. Our internal committees and pharmacy create and maintain guidelines, protocols, dosing limits, and various alerts/reminders. We have 2 full time RNs just to maintain our chemotherapy protocols.

Many hospitals and academic institutions do not have the resources to create and maintain their own best practice protocols, guidelines, and order sets. The amount of new evidence produced every year exceeds the capacity of any single committee or physician to review it. The only way to keep knowledge up to date is to divide the maintenance cost and effort among many institutions.

A number of firms have assembled teams of clinicians and informatics experts to offer these kinds of knowledge resources. UptoDate maintains world class clinical information with thousands of authors reviewing literature and providing quarterly revisions.  Anvita Health has a large team of experts codifying decision support rules and building the vocabulary tools needed to make them work with real world clinical data. Medventive provides the business intelligence tools needed to create physician report cards and achieve pay for performance incentives.

However, none of these firms can plug directly into an electronic health record in a way that offers clinicians just in time decision support.

Here’s a strawman for the way a Decision Support Service Provider should work:a. A hospital or clinic selects one or many Decision Support Service Providers based on clinician workflow needs, compliance requirements and quality goalsb. Electronic health record software connects to Decision Support Service Providers via a web services architecture, including appropriate security to protect any patient specific information transfered to remote decision support engines. For example, an EHR might transfer a clinical summary such as the Continuity of Care Document to a Decision Support Service Provider along with a clinical question to be answered.c. A clinician begins to order a therapy or diagnostic test. The patient’s insurance eligibility and formulary are checked via a web service. The patient’s latest problem list, labs, and genetic markers are compared to best practices in the literature for treating their specific condition. A web service returns a rank ordered list of desirable therapies or diagnostics, based on evidence, and provides alerts, reminders, or monographs personalized for the patient.d. Clinicians complete their orders, complying with clinical guidelines, pay for performance incentives and best practices.e. The decision support feedback is realtime and prospective, not retrospective. Physicians get CME credit from learning new approaches to diagnosis and treatment.

In order to do this, EHR vendors must work with Decision Support Service Providers to implement the uniform architecture and interoperability standards needed to integrate decision support into EHR workflow. I would be happy to host a Harvard sponsored conference with all the stakeholder companies to kick off this work.

Of course, some may worry about the liability issues involved in using a Decision Support Service Provider. What if clinicians comply with flawed guidelines or fail to comply with suggested therapies and bad outcomes occur?

Based on my review of the literature, I believe decision support liability is a new area without significant case law. The good news is that there are no substantive judgments against clinicians for failing to adhere to a clinical decision support alert. As a licensed professional, the treating clinician is ultimately responsible for the final decision, regardless of the recommendations of a textbook, journal, or Decision Support Service Provider. However, as Clinical Decision Support matures and becomes more powerful and relevant, I believe that there could be greater liability for not using such tools to prevent harm.

This blog entry is a call to action for EHR vendors and emerging Decision Support Service Provider firms. It’s time to align our efforts and integrate decision support into electronic health records. Working together is the only affordable way for the country to rapidly implement and maintain high quality decision support and information therapy.

John Halamka is the CIO at Beth Israel Deconess Medical Center and the author of the popular Life as a Healthcare CIO blog, where he writes about technology, the business of healthcare and the issues he faces as the leader of the IT department of a major hospital system. He is a frequent contributor to THCB.

Categories: Uncategorized

11 replies »

  1. So this is Health Care Reform at its best, please allow me to share a concept that will open your mind in a way never thought of for a United Forum Concept. At first I stood alone and I wrote my first blog and little did I know that thouands of people and companies stood by it,
    I have waited to see the issues of tax increase and health care, something that may be wrote by President Obama,
    You see a lot of what I write, is in fact that, I do not seek Political support because I do not belong to any party. As for President Obama and theses 60 people that hold seat of Government who wish to build 1900 page of law to Govern this system because of this Health Care dollar. I watch them stumble about without a clue of how to fix this failed system. To see into this failure, you must allow this system to be seen as a forum for dollars of taxes created as a constant as a yearly figure. This prediction of dollar for the future, is in fact what I call Artificial Intelligence built on the hope that taxes will stay a constant figure.
    This Health Care Forum we offer is built on a moral value, a strategic forum to place issues to work ,that offers freedom to be a part of it or not. This force pay against companies, force pay against VETS, and so on shows the lack of a moral building block within this Health Care Reform.
    What we offer is that, will, Lets use the AARP Health Care Insurance Company, and lets say that they have 30 million members. To show that this company can earn $150 million dollars per month and be released from the burden of medical cost, by what we wish to show as health care tax forum and a freedom of choice for a pay in to a forum to a Insurance Company for people who do not trust this system within The United States Government. A tax forum forces the Goverment system to work for the people and at the same time forces Government Officals to work for the people within this forum.
    To reach out to a company and sit down with them to build something never attempted in order to rebuild lives and the National Security of The United States as a moral building block without laws to Govern, but to protect this system from crime is what a moral law use to stand for.
    To show a $100 trillion dollar strategic building block by companies of freewill that step forward to help rebuild America. To build the most powerful anti war / crime forum ever conceived by such as I a nobody that only seek to only go back to work as a painter and rebuild his little company dream.
    As stated at first I stood alone against so many and I have found the uniting of people of different faith that seeks the same as I do. What makes FASC Concepts different, we do not ask for money and we opened a door for people to put their faith into themselves as a person and not what we say, to build on this and protect it under the concepts of law such as the Patriot Act. {A Moral Concept}
    There is a day coming that Officials of Government will see that the Laws built against God and Country was the first steps of the United States Of America headed for failure because it lacks moral value. This is what our enemies see, a Country of Laws that should of never been created by few against so many people of the USA.
    Is it so hard to see a concept for a Health Care Stimulus Package that builds jobs and life within a anti / crime forum ?
    Henry Massingale
    FASC Concepts in and for Pay It Forward
    found on google.com. And yahoo look for page 1 american dream offical site.

  2. Why do We need 2100 pages of BS to reform Health Care, Probably could be done easily with something simple. Remember there are only 10 COMMANDMENTS. We have progressed to a point that the only way to solve a problem is to create 1,000 more problems.
    Thomas Jefferson said “When the people fear their government there is tyranny; when the government fears the people, there is liberty.”
    A suggested Amendment 28
    Congress shall make no law that applies to the citizens of the United
    States that does not apply equally to the Senators or Representatives,
    and Congress shall make no law that applies to the Senators or
    Representatives that does not apply equally to the citizens of the
    United States .

  3. Hello. Very interesting article. Just finally getting around to reading it. Wanted to let you know about MEDgle (http://www.medgle.com/ ). Though we have not phrased it as a Decision Support Service Provider, that is a very succinct way of saying what we do.
    We have cross connected 10,000+ symptoms, 2100+ diagnoses, 6000+ procedures, 5,000+ medications, and age,gender and lifestyle with associated probabilities and algorithms to provide the basis for decision support service for consumers, health care providers, and 3rd party applications.
    We have recently beta tested our API with the folks at MycaHealth/HelloHealth where they have used our decision support APIs to power their assisted documentation component. Others are currently in the works. If it is of interest, would be more that happy to share the restful API. Also, if you do have a conference or meetup, please do let me know.
    Ash Damle
    CEO, MEDgle

  4. With due respect to Dr.Joshua Seidman I challenge the very premise that information is therapy.
    So Ix (Information Therapy) is an inherent oxymoron.
    Quality Information is obviously extrememely important for medical providers and consumers. But it is not therapy.
    It is well known for example that information alone does not change behavior (see smoking issue. Read stages of behavioral change research
    Certainly information does not give 21st century US medicine what it needs most which is FAIRNESS
    Dr. Rick Lippin
    PS -Ironically I have written on the power of words to heal

  5. Instead of step a. hospital or clinic selecting a DSSP vendor, why doesn’t a large self-insured employer group (a leader like a GE or Wal-Mart) select a vendor and make a “health information therapy” option available to all of its employees? The purchasers have the most to gain from this concept, and they have the population health data to know which DSSP providers would best be able to reduce their costs. Its understood that the physician workflow is a key component to this, but why not start with the data feeds to build the health records for all employees with supporting DSSP analytics, and then as a first step supply results from the DSSP vendor(s) via outbound phone calls to the docs? A firewall between the DSSP service and the employer would maintain the privacy of the patient records, and the employee could pick a Google or MS to “bank” their records in standard format that supplies the DSSP; this way employers are not holding their PHI, and the patient’s data is portable to the next employer. Patients might also want to continue on their own with the DSSP service initially selected by the employer. The employer would be evaluating the vendor(s) it chooses by looking at its own medical cost trends over time, even picking new DSSP vendors based on changes in its populations’ health. Finally, back to the docs, if they find the phone call messages useful, and patients are making appointments based on the alerts, then the physician workflow can come later as an efficiency tool for practice management. This way if the disruption to physician workflow resulting from EHR implementations is too much of a barrier and we never get broad national adoption, then we can still make progress in this worthy area using good old fashioned phone calls! Best of all, if the docs find the data wrong, or not useful, they can simply ignore the phone calls, or work with the vendors to improve the information. SO, rather than flushing billions of dollars down the drain on EHRs, which most docs don’t want anyway, why not engage them in these efforts with purchasers, so they can help define the information they want/need, then if the analytics work, we can figure out ways to get them the information timely and in the most efficient way possible. The data exchange is low hanging fruit, the information we use is the ‘holy grail’.

  6. This is definitely a big step in the right direction… the only way out of the current EHR mess is through interoperability and portability that come from common standards. Decision support is just one of many applications that could be built once standards are in place.
    As an outsider to e-Health, it seems that there are standards about standards, but no standards: there’s a lot of talk (and agreement) about what a nationally-accepted standards should do, but no publicly available spec that I can find in weeks of research.
    For eHealth to be practicable, we need to *demand* that all medical software vendors provide useful APIs and web services. Down the road, this standard should be broadened to include RDF and the semantic web. This will provide an intelligent way of navigating the large amounts of medical data out there — and the ability to draw inferences from it.
    You also mention remotely hosted solutions: there is definitely a huge role that software as a service (SaaS) and cloud computing can play in lowering costs.
    Thanks for pointing us the right direction…

  7. Excellent post. Couldn’t agree more.
    Although you’ve probably mentioned this in previous posts and others in the community may be well aware, I think it’s important to note potential conflicts of interest. In this case, for example, that you serve on Antiva’s Board of Directors.

  8. Perfect timing. This is the one point that Ken Mandl and Zac Kohane should have added to their recent New England Journal article on Open Platform electronic health records (http://content.nejm.org/cgi/content/full/360/13/1278).
    This is the type of environment for which we’ve targeted our SimulConsult diagnostic decision support software. Top level diagnostic decision support is something that naturally has a global scale, not institutional scale.
    This is a good time to get people focused around such open standards.

  9. It’s not affordable if you cut physician and nursing productivity in half like my hospital’s latest rollout loser EHR.

  10. To control the pain we must attend to the specialist because we can give him what is appropriate and what we need, for example I take Oxycontin, which is a medicine used to counter the chronic pain that I have for years, but I rioja prescribing doctor, I take it in moderation because I read in findrxonline..com which is a medicine that causes anxiety, and we must control it as it can affect your nervous system, so do not take medicines without consultation because it really can be dangerous.