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IT: Notes From A Parallel Universe



January 26th, 2007

Many reports on health information technology in the past few years tell a tale of a dream deferred — standard-setting deadlines blown, adoption targets undershot, groundswells of demand dematerializing. But in the alternate world of large, integrated health plans, where the better angels of our troubled system’s nature may be said to reside, some of the future promise of health IT has already arrived. The possibilities of a “rapid-learning health system” are laid out in detail in a collection of papers published online today by Health Affairs.

A few of these integrated health plans, which have fully deployed electronic health records up and running, have begun to use their systems to answer practical research questions on the effectiveness of new treatments that would take years to answer using such traditional methods as randomized controlled trials. At a time when the pace of scientific innovation has outstripped the capacity of the existing clinical research infrastructure, and while oceans of patient data sit in vast, disconnected repositories “untouched by human minds,” a golden opportunity to accelerate clinical learning presents itself. And some of these organizations — including the Veterans Health Administration, Kaiser Permanente, and the Geisinger Health System — have seized it.

For example, since its transformation into a “wired” system in the 1990s, the VHA has developed a diabetes registry that holds detailed clinical data on 600,000 patients, which allows the system to track and manage higher-risk patients well enough to improve clinical outcomes by large orders of magnitude. Similar public program potential exists to enhance postmarketing surveillance by the FDA and help Medicare use patient data to make coverage decisions.

Like health IT, evidence-based medicine has been touted by the health services research community for decades as the answer to the health system’s troubling quality failures and unexplained variability. The history of evidence-based guidelines has been a checkered one, in large part because of medicine’s resistance to standardized practice. But Paul Wallace’s account of the use of rapid-learning approaches to standardize cancer care at Kaiser Permanente shows that standards and variations are two sides of the same coin in real evidence-based practice, which can be used together to enhance both best practice norms and clinical discretion for individual patients — laying to rest the canard of “cookbook medicine.”

The possibilities for expansion and enhancement of rapid learning opportunities, and the policy implications of these new vistas, are outlined in an overview paper by Lynn Etheredge.

Click here to view a webcast of a briefing on the rapid learning collection, which will be available on Tuesday, January 30, at 12 p.m. EST.

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2 Responses to “IT: Notes From A Parallel Universe”

  1. annecarroll Says:

    To give a different perspective on Chheda’s comment: planning and standards must come from top-down, while a bottom-up approach may be appropriate for implementation, support, and diffusing the use of IT and health information throughout the individual practice sector. Both of these activities must be done simultaneously. Relying only on a bottom-up approach will not address the barriers to adoption that physician practices have identified: cost, lack of familiarity with information technology, fear of the need for constant upgrades, lack of capacity to evaluate new technologies, confusion arising from the need to know and use different systems at different hospitals where they have privileges.

    Another urgent reason for top-down planning and standards is the need for public health agencies at the state and local levels to carry out their responsibility for health status surveillance at the community level. Greater penetration of syndromic surveillance capacity is required to detect non-routine situations such as emergent diseases, exposures to environmental pathogens, etc., as well as to evaluate the outcomes and impacts of public health interventions in the community. The current patchwork system of required reporting of a limited subset of diseases and observations is underused, confusing, provides little actionable knowledge, and reveals the inefficiency and ineffectiveness that is the outcome of one-way systems development. Developing these kinds of capabilities depends on top-down standards and planning by federal, state, and local public health acitvities with the provider communities as well as bottom-up support in their implementation and capacity development to remove the barriers to their adoption.

    Finally, top-down planning and standards developed independently from the way health care is delivered enable future development of technology that builds the capacity of providers and supports new learning from medical and health care data. If individual practices or HMO’s went away tomorrow, or if different kinds of data must be collected or different knowledge about outcomes must be analyzed, or if a provider decides to use a new technology, the top-down plan and standards provide a roadmap for how to get to a new destination. For an analogy, we frequently point to the 2×4 board as a standard for the construction industry: it is flexible enough to be used in many different kinds and styles of buildings, it does not restrict future designs or uses of buildings; yet it is also beneficial for planning a project, for budgeting, and for understanding how a project will be engineered and implemented.

  2. Nainil Chheda Says:

    It has been argued by variety of industry leaders that even thought there are many such nationwide systems trying to interact with each other and exchange relevant patient data, the truth still remains true that if there is not enough penetration of the EHR industry amongst the physician practices the system will fail.

    There needs to be a bottom-up approach and not a top-down approach. The top-down approach leads to the creation of various nationwide systems and standards first and then looks for the availability of electronic health record amongst the physicians. However the bottom-up approach first creates a need for the electronic health records amongst the physicians; and then joins them together to form nationwide architectures.

    Even though there is a good possibility of the rapid learning systems evolving quickly, the base questions are still left unanswered: – “What are the risks involved in creating a central repository of patient relevant information?”, “Who owns the patient data?” and “What are the barriers to the growth of these rapid learning systems”.

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