Grand Rounds & Health IT: The man behind the curtain is..... Forrest Gump?

Good reading awaits at this week's Grand Rounds, where Dr. Joseph Kim invited bloggers to share how IT is changing healthcare.

Healthcare is full of tech-facilitated miracles. I think health care technology's best successes so far lie in applications aimed at individuals. My daughter's cochlear implant is one great example.

A cochlear implant (CI) does not make my daughter a "hearing person." But it certainly gives her the opportunity to access sounds and to make meaning of them in a way that's very similar to what people with normal hearing can do.

Deaf people don't have surgery and wake up "hearing" any more than you buy a computer and become Bill Gates. To realize the full potential of a cochlear implant, a user learns to make meaningful use of the data the implant provides.

Implant users can hear--and grasp the significance of--a toilet flushing almost immediately. But understanding and mastering a complex battery of sounds--like syllables, words, and sentences--has a much longer learning curve. Gaining meaningful use of a cochlear implant also requires concomitant support that's not technical at all: early education for language acquisition and ongoing speech therapy.

Think about another IT-facilitated product that fosters miracles: digital radiography. A lay person can see that digital images are sharper, brighter, more precise than those on old-fashioned films. But knowing what's normal, what's a normal variation, and what requires follow-up takes education and experience, an intimacy with both the imaging device and the anatomy it captures. Like a CI, radiography only becomes meaningful when the data is interpreted, communicated, and factored into a larger whole.

System-level application of IT, a late-comer in healthcare, is likely on a similar journey toward meaningful use. Right now, I'd say health care stakeholders are hearing toilets flush and noticing that some things are brighter than others.

I think there's a lot of other things that could be said about that.

But since I'm feeling a little like Forrest Gump today, I think that's all I'm going to say.

Medication safety: It's hard to be (a) patient!

Patients for a Moment is a new blogging round-up, one that collects stories from patients and people interested in the experiences of patients. I joined in this week and shared a short piece about what safer prescribing would look like. There's a lot going on with medication safety in other venues as well. The FDA just heard recommendations from an advisory panel, and it's looking like consumers are going to get some help in managing risks associated with acetaminophen.

A few weeks ago, I listened to an excellent webcast about medication management and safety aimed at health care professionals (click here to go to the link to hear the re-broadcast). In the U.S., approximately 25% of all reported medical errors involve medications. The most important "take-away" I heard occurred when Peter Angood, a physician leader in the patient safety movement (someone intimately familiar with medication safety risk points), shared how his drug history had been botched during a recent outpatient procedure.

The communication infrastructure surrounding medication use is so poor that the system breaks down for patient safety experts with relatively uncomplicated medication profiles undergoing scheduled diagnostic procedures? Yes. Routinely. Bet on it. Good luck to the rest of us.

Dr. Angood's story serves as yet another "call to action" as people in the United States consider how to spend $20 billion dollars to make healthcare IT serve patients and providers in meaningful ways.

Here's the take-away for now: While we await better integration of electronic medication data, go ahead and establish an electronic medication record of your own. ISMP's Consumer Med Safety website, in conjunction with iGuard, offers a free MedSafetyAlert! service for listing and tracking your medications. It's easy to use, and iGuard's medication platform is being adopted by larger electronic medical record systems, meaning that the data you enter will likely "flow through" to more sophisticated e-health record keeping systems (maintained by you, your caregivers, or a healthcare facility).

Based on the information you enter into MedSafetyAlert!, you'll receive tailored alerts and monthly summaries via e-mail. I've used the service for several months, and found it to be simple, non-invasive, and easy-to-access.

Meaningful Use: Your prescription shouldn't have to look like this

I spent a year studying medication safety at the Institute for Safe Medication Practices, the nation's only patient safety organization devoted solely to medication error prevention and safe medication use. So I'm always on the lookout for ways to help others see what I learned to see.

My friend had a friend-of-a-friend deliver a load of pine straw to her home the other day. The delivery man left an invoice, and my friend asked me to interpret the name of the company so that she could write a check.


Take a look and see what you think.

I guessed "Chevrolet" (even though it seemed like a weird name for a handyman service.) My friend frowned. She's a middle-school math teacher, and she's detailed-oriented. "Leave it blank," I suggested, "and mail it. Mr. Pinestraw can fill it in." More frowning. (This suggestion was clearly not welcomed by my friend, one of the most reliable people I know, someone who dots her i's and crosses her t's and is not in the habit of leaving things blank.)

Several days later, my friend mentions she's going to drop the check for Mr. Pinestraw off, having finally tracked him down via telephone and clarified the name. "Cherokee!" she says triumphantly!

To average Walmart shoppers like myself, health policy and IT discussions about how $20 billion dollars in economic stimulus funds are going to be put to meaningful use sound a lot like Charlie Brown's teacher: "Waoao waoaoa waoaoa wah woaoao."

So, let me draw on the med safety expertise and call out a few suggestions for how I think monies spent for meaningful health IT should be visible to healthcare consumers:

1. People who prescribe medications should use a system more sophisticated than the pine straw delivery guy's to communicate high-stakes drug information. 1,400 commonly prescribed drugs have names that look-alike or sound-alike. People can, and do, die when drug names are confused with one another.

2. Pharmacies should be able to receive prescription data in a format that does not require the tenacity of a middle-school math teacher on summer holiday to decipher.

3. Your electronic medication history--housed with your physicians, pharmacy, and any consumer portal you choose--should move seamlessly into hospital data repositories and be accessible, with your consent, during planned and emergent encounters.

Meaningful Use: What Flo Knows

The term "meaningful use" describes the way health information technology should be put to work to improve population health, individual health, and system efficiency. Stakeholders have been aTwitter (search #MU) because IT applications/solutions that meet "meaningful use" criteria will be able to snag a piece of the $20 billion ARRA monies.

If you're new to how the delivery of health care impacts outcomes, you can join those of us who have been screaming and clawing our faces for some time by perusing these dismal stats:

• 2009 estimates of infant mortality rates (considered a reliable indicator of the level of health in a country) show the US at 6.26/1,000, behind Sweden's 2.75/1,000, Germany's 3.99/1,000, and the U.K.'s 4.85/1,000. (We're 2 notches up from Croatia, which posts 6.32/1,000)


• For every $1 spent on health in the US, our G-5 competitors spend $0.63

Meaningful use should not define health IT. It should define what health IT enables: meaningful use of information technology to achieve desirable outcomes. This is what IT has done for every other sector of the economy, including the Amish micro-economy, in which people--who are as-off-the-grid as you can get--manage their agriculture and cabinet-making businesses (albeit with generator-powered computers).

If the Amish comparison is too far out for you, here's what Ivan Seidenberg, Chairman and CEO of Verizon Communication, said in the The Business Roundtable Health Care Value Comparability Study, published earlier this year:

"When it comes to scientific advances, medical technology and the quality of our doctors and hospitals, the American system is robust. But health care is beyond the reach of an increasing number of Americans. From our perspective, the problem with the U.S. health care market is that it doesn’t really function as a market – it leaves major consumer needs unmet, costs unchecked by competition and basic practices untouched by the productivity revolution that has transformed every other sector of the economy." (emphasis mine)

I've got to believe that the productivity deficit Seidenberg calls out has something to do with how IT works (or doesn't) to achieve operational efficiencies. IT doesn't move us toward a healthcare whole although it's certainly been harnessed to great benefit for individuals lucky enough to be able to access high-end care (just ask me or any other parent who talks to their cochlear-implanted kids on a cellphone).

When patients seek care or healthcare workers go to work, IT doesn't show up in the ways we've become accustomed to. Oh, it works in the piecemeal, "best of breed" way that we've asked it to, supporting the piecemeal "best of breed" health system we've concocted. But IT, as currently designed and implemented, is wholly insufficient for the complex tasks-at-hand.

Yesterday, a preliminary report from the Health IT Meaningful Use Workgroup was made public. Not everyone is happy. And there may be opportunity to improve on the first stab. But so far, I've found the preliminary Meaningful Use materials to be true to the IOM's Six Dimensions of Care, elements seen as the backbone of a healthy health care system.

Safe, effective, timely, efficient, patient-centered, and equitable. The Big 6, first defined in Crossing the Quality Chasm, the road map to healthcare improvement we've been asked to follow for the past 8 years. Only now, we may have meaningful IT vehicles to help take us there.

Grand Rounds: More than good stories found

One of the things I like best about Grand Rounds is that I find inspiration to help bring my hodge-podge of loose thoughts and impressions together.

Healthcare reformers and activists have begun to focus on the $20 billion American Recovery and Reinvestment funds that--God-willing-and-the-creek-don't-rise--will make IT in healthcare "meaningful." The National Committee on Vital and Health Statistics' Report of Hearing on "Meaningful Use" of Health Information Technology captures multi-stakeholder concerns well. It's a worthwhile read about the realities we face in harnessing strong IT solutions to transform healthcare efficiency and outcomes.

I jumped at the chance to talk about meaningful use last week, both here and over at On Your Meds, the Medscape medication safety blog I write. Although I'm techy by nature, it doesn't take a specialist to see that the current state of IT often makes front line clinical people tie the horse to the Edsel's bumper to advance a care goal. (If you missed Gina's story a few weeks back, it's worth a read to sample just a few of the unintended consequences front line clinicians face when e-systems fail to communicate.) So I posted call-to-action pieces about meaningful use, advocating for IT outputs that would make patient data central and help get front line clinicians out of the manure.

Then I started reading what cutting edge e-patient advocates and health 2.0 innovators were saying about what "meaningful use" might really mean. E-patient Dave's remarkable story is one that has drawn attention to health IT's intention-outcome mismatch. The power of high-end patient involvement left me feeling that my "make it work for those on the line" approach was like suggesting we replace "Mr. Ed" with "Rachel Alexandra" on the bumper.

But today at Grand Rounds, I stumbled across the story of a man, and his family, movingly told through the fresh eyes of a soon-to-be nurse in Brain Death, Part 3. The patient and family in the story, especially when contrasted with e-patient Dave, show the vast continuum of abilities and circumstances of people in our care.

We most certainly need to get the horses off of the bumpers. But we also need to be certain that we advocate for models of care--which are ultimately what IT solutions support--that allow all kinds of horses to make it around the track.