Monday, November 12, 2007

Data, Information, Knowledge, and Wisdom

One of the challenges of being a doctor in the 21st century is information overload. More medical literature is published every year than a doctor can read in a lifetime. As electronic health records become more common, doctors can be overwhelmed with data gathered about each patient. Doctors do not want to review hundreds of normal findings, they want to know what is actionable for each of their patients to keep them healthy

Healthcare CIOs should implement applications which filter data so that it becomes information, transform information into knowledge, and ulimately provide clinicians with wisdom based on that knowledge at the exact time they need it.

Here's an example. Suppose a patient's blood pressure is 100/50. That's data. Suppose that patient has a ten year history of blood pressures of 150/100. That's information. Suppose that the patient has a known history of coronary artery disease and is now experiencing chest pain. The sudden drop in blood pressure could indicate a serious myocardial infarction in progress. That's knowledge. It's time to give the patient an aspirin, oxygen, and nitrates immediately. That's wisdom.

Recently, I asked my primary care physician to export my entire history from his electronic medical record system. Although I'm a completely healthy person, the result was a 77 page PDF. The document contains a mix of administrative and clinical data, numeric observations and unstructured text. It would take a physician about an hour to navigate all this data.

How can we turn this data into information? Over the past few years, my clinical information systems team, led by Dr. Larry Markson, has built "event driven medicine" into our applications. Events such as changes in medications, patient visits for diagnostic testing, lab results, or newly discovered allergic reactions generate data which can be transformed into actionable wisdom. Here are three examples:

When a doctor writes for a medication at BIDMC, a query is sent to our regional data exchange determining the patient's insurance coverage for pharmaceuticals. Based on the answer, we access the appropriate payer-specific formulary so that all medications are preferentially chosen to minimize cost and maximize effectiveness for each patient. Every prescribed medication is checked against the entire history of the patient's active medications from pharmacy and payer databases throughout the country. Safety issues, guidelines and best practices are displayed to the clinician, ensuring quality care. When the correct, safe medication in the right dose is selected it is instantly routed to the pharmacy of the patient's choice, going from the doctor's brain to the patient's vein without any handwriting or human interpretation. All of this happens in real time based on the data found in electronic health records, information about trends in body functions, knowledge from decision support databases, and wisdom from the orchestration of all these moving parts behind the scenes via interoperable web services, ultimately providing the best choice for each medication written. This week, we just completed our 100,000th medication processed this way.

When a doctor orders a radiology test a BIDMC, a query is sent to a decision support engine which we co-developed with Safe-Med. Over 1000 best practice rules from the American College of Radiology and the world's radiology literature are examined, along with patient medications, laboratories, allergies and demographics, to select the most appropriate radiology test based on evidence. Radiology exams are scored from 5 stars to 1 star (the image shown above), balancing efficacy, risk and cost. If a clinician orders one of these tests, a pre-authorization is sent to the payer in real time and the test is automatically approved. All of this happens in a few seconds, using patient data plus the knowledge from the literature to yield a wise choice for radiology diagnostic testing. 100% of high cost radiology tests are processed this way.

When a doctor identifies a chronic diease condition at BIDMC, a decision support "screening sheet" is created to track all the events in a patient's care. Diabetic tracking includes lipids, glucose, eye exams, foot exams, Hemoglobin A1-C, immunizations, and weight. Whenever an event occurs - such as a lab result or appointment, the screening sheet is updated and decision support rules recommend the best practices for diabetic care, filtering all this data into a concrete set of recommendations such as "patient is past due for an eye exam" or "patient should receive pneumovax this season". Clinicians do not need to focus on the raw data, instead they can review suggestions in real time to optimize the care of the patient. This year we achieved all our pay for performance goals using this approach.

Like many other projects, the pursuit of event driven medicine is a journey. Over the next few years, we'll continue our efforts to ensure that clinicians are given the real time wisdom they need to deliver safe, cost effective and appropriate care.


Ileana said...

This is extremely interesting. I suppose the physician can drill down to see the raw data that the suggestions are based on? You don't want the patient started on medication without checking that the low blood pressure is indeed low and not caused by an uncalibrated machine or some other issue.

Do you have monitors in each room (what size?), or do you use tablets or laptops that each user carries with them? We like to build applications that run on large screens with lots of information, so you don't have to navigate from screen to screen, but see what's essential with one glance - or one drill down.

John Halamka said...

Great question! We have 50 inch plasma screens in our ED, OR, PACU, and procedure areas. We have subnotebooks on carts in every critical care area and 1 desktop for every 2 beds throughout the hospital. We have 2 million square feet of wireless for clinicians, staff and patients.

The raw data is always available and we have processes to ensure every abnormal result is signed off, but clinicians are given the choice of looking at raw data, summaries or alerts/reminders from our decision support systems.

Ileana said...

Sounds like Star Trek :)

I'm very surprised that this post did not raise more comments. The hardware, operating systems, network, watts and your gadgets are of course each important to the whole operation, but this IS the business. I think it would be interesting to hear more about it.

And while I have the stage, let me ask questions from my turf to be considered as subjects for future posts:
- Is database independence important for you? If yes, why? Do you start with an open source database and want the flexibility to change it in the future?
- Did you have an application that did not perform as well as it should have (in terms of response time)? How did you resolve this: tune the code to decrease network traffic, increase bandwidth, use better servers?

globetrotter said...

Hi John,

This is fascinating post, and very readable with all of the examples. Thanks for posting it!

Bob Coli, MD said...

Dr. Halamka,

The problem of fragmented, incomplete and variable formats for reporting hospital and ambulatory patient test results persists as a costly and dangerous legacy of the mainframe era.

In the emerging interoperable HIT systems era, the simple solution is to substitute a clinically integrated, comprehensive and standard format. Doing this will reduce the number of screens and pages by 75 percent and allow caregivers and patients to efficiently view and share cumulative test results across all points of care.

A private-public sector collaboration is now underway in Rhode Island to implement such a clinical application standard in a manner that will benefit all of the stakeholders in the statewide HIE Project.

Based on your description of the BIDMC's s system and my review of SafeMed’s Web site, I am certain that integrating workflow-friendly clinical decision support into this standard format would add substantial additional value for its physician users.

Bob Coli, MD,
Founder and Chairman
Diagnostic Information System(SM) Company
Warwick, RI

Unknown said...

"It's time to give the patient an aspirin, oxygen, and nitrates immediately. That's wisdom."

Don't do that !!

Don't give nitrates to the patient that has so low blood pressure ... This patient needs urgent catlab, but wait with the nitrates, the pressure can drop even further.