Healthcare is in a moment of transformation that is coming at a bewildering pace for some and not soon enough for others.
The most progressive healthcare organizations are implementing a new vision – using information and events occurring in the course of care to recognize trends and patterns, and to act upon them immediately. They are able to influence outcomes rather than to react to them after they occur. It’s what we call Event-Driven Healthcare. But none of this is possible without the cornerstone of integration and interoperability.
Integration is Job One
The importance of integration in healthcare is nothing new. Dr. David J. Brailer, MD, PhD, a former United States public health official, perhaps best known as the first “health information czar”, summarized it this way in 2004:
“Unless interoperability is achieved, physicians will still defer IT investments, potential clinical and economic benefits won’t be realized, and we will not move closer to badly needed healthcare reform in the US.”
Some healthcare organizations are clearly at the forefront of this sea change. Take for example University of Chicago Medicine or Vanderbilt University Medical Center which are advancing the way clinical decision support is used for improving outcomes.
But now, even nine years later, most healthcare organizations are still at the nascent stages of the curve. Most remain fixed in an era of inflexibility that leads to service delivery issues and skyrocketing cost of healthcare.
Healthcare Data is Getting Bigger – and Faster
The volume, velocity, and variety of data involved in patient care are growing. There is an ever-expanding number of medical devices sensing and sending clinical information, and clinicians are using mobile devices at the point of care. They need to have the right information, at the right time, in the right place, and in the right context for making the proper decisions about patient care.
The fact that a patient is allergic to a medication does a clinician no good if that information is locked somewhere in the bowels of an EMR.
Short-Term Payback, Long-Term Transformation
With hundreds of business and clinical systems, the typical healthcare organization has thousands of connecting points. In a traditional environment, this means countless hard-coded point-to-point interfaces that are inflexible and expensive to change.
By integrating systems with a 21st century platform, the number, cost, and degree of maintenance of systems interfaces are reduced dramatically. And most importantly, critical clinical information and events are visible throughout the network and available in real time for clinicians to take action on.
Any Journey Begins With a Single Step
Transforming the healthcare industry, or a single organization, surely will not happen overnight. It takes keen long range vision to progress along the maturity path – to connect systems, authenticate information, operationalize data and events, and establish a secure social collaboration network. But clinical value and ROI can be achieved at each stage.
Mercy Health, a large hospital system based in St. Louis, started with such a long-range plan and began its journey with system integration, speeding time to market and reducing cost for system updates. Ultimately, with real-time information flowing freely across their network, they now monitor multiple data sources and trends over time to identify patients in need of immediate life-saving intervention.
In healthcare, the availability, accuracy, and context of clinical information can make the difference between life and death. It all begins with integration.
Learn more about the critical role of Healthcare IT in the 21st century.
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Doug,
I realize, the same word often has different meanings, but I hope my understanding of integration meshes with yours. Several years ago, while designing medical diagnostic assistance, I realized, using colors to convey finding sensitivity and specificity will let clinicians fully process diagnostic info and integrate use of all patient and care information. The proposed technology consists of 1) a highly modular knowledge base of diagnostic and other care information, 2) imported into a relational database of care and patient data, and 3) applications which can process that data in various ways. I believe that technology can be used to make EHR systems much more functional and user friendly. If you’re interested, I’d like to send you material describing my work.
Mark
Having worked with the Veterans Health Administration for over 30 years and having seen the value of patient data integration, when I saw the lack of patient data integration in the U.S. private sector as a member of the Pennsylvania Governor’s Commission on Chronic Care (2007-2010), especially as that affects the delivery of care to those with chronic illnesses, the category of care accounting for way more than 50% of our health care costs, I worked with collaborators from Marshfield Clinic and elsewhere to produce this volume: Integration of Medical and Dental Care and Patient Data (Springer-UK, 2012: http://www.springer.com/public+health/book/978-1-4471-2184-8) Certainly the mouth is part of the body. Please see Appendix C of this volume, Contact Points between Medical and Dental Care and Research. If you want to help with a second edition, please let me know.
Valerie Powell
Dr Powell:
Some additions to your excellent book (that I have bought, scanned and am in the process of reading in detail) for the purpose of “integrated thinking” and facilitation of much more cost-effective dental, medical and ophthalmic care:
1) A model for the systemic relationship between some serious medical conditions and some serious dental disorders:
Some medical conditions endothelial dysfunction Some dental conditions
Some ophthalmic conditions (e.g., keratoconus) endothelial dysfunction
Physical, genetic, psychological, environmental, mental factors -> oxidative stress -> endothelial dysfunction -> microvascular dysfunction -> regional and micro-regional blood flow abnormalities -> “Downstream pathologies” facilitated such as diabetes-related microvascular pathology, microvacular-related renal insufficiency, cerebral microvascular disease, depression, menopausal transitional symptoms, PMDD, PTSD, ADHD….etc
2) An “integrated model” of Disease Onset, Progression, Recovery, Complication that accounts for medical and non-medical factors:
Onset of Disease
Risk Factors, if present, increase the probability of Onset of a Disease
Protective Factores, if present, decrease the probability of Onset of Disease
Progression of Disease
Stress Factors (mental and physical and environmental and psychological), if present increase the probability of Progression of Disease
Resistance Factors, if present, decrease the probability of Progression of Disease
Recovery from Progressed Disease
Antagonistic Factors, if present, decrease the probability of Recovery (or “Bounce Back”) from Progressed Disease
Resilience Factors, if present, increase the probability of Recovery from Progressed Disease
Complication of Disease
Risk Factors, if present, increase the probability of Onset of Disease Complication
Protective Factors, if present, decrease the probability of Onset of Disease Complication
3) A hypothesis: With well trained clinical medical / dental / ophthalmic assistants working in medical / dental / opthalmic care offices and with integrated data and decision support systems, it is possible to facilitate access to high quality, safe, cost-effective medical, dental and ophthalmic care.
I suggest that you and your distinguished colleagues (inside and outside Robert Morris U.) consider writing a grant for the establishment of an International Academy of Integrated Care in the Azores for the purpose of facilitating the above AND submit grant requests to the World Bank (while incorporating the World Bank’s very extensive thesaurus) for this purpose.
In addition I suggest you utilize whatever integrated data model that the VA, DOD and DVB develop to build your integrated data model and decision support system
In addition I suggest that you look to the country of Sweden for three reasons: 1) use of HealthShare to integrate ALL the patient care data of that 9,000,000 person country; 2) use of a multidisciplinary intervention list (that includes nursing dx and rx’s) as part of their national data and outcome monitoring system; 3) use of the roll up nationally of health care injury claim data connected to a “no fault” health care injury claim adudication system that obviates the need for the tort system. 1,2,3 have the purpose of facilitating continuous quality improvement with evidence-based cost-effective care that is monitored, modulation and iteratively changed.
#3 in Sweden, if implemented in the US could garner support from practicing physicians and BIG PHARMA. Regarding BIG PHARMA, please note the industry connotations about the recent jury award of 21,000,000 dollars from a generic medicine distributor and a patient who had a very rare side effect (toxic epidermal necrolysis) from taking sulindac, a very low cost and complication free NSAID that even has proposed anti-cancer effects. The implications of this award are a catalyst for support by BIG PHARMA of efforts such as yours.
Charles Beauchamp MD PhD
clinicsforhumanity AT yahoo.com or via linkedIn
Dr. Powell:
Suggest differential diagnosis -> define key questions to ask to ask for entities in the differential diagnosis -> patient presents to dentist (or medical provider) -> computer administered questionnaires based on HIE - EMR - Triage clinical note intersection for: 1) patient, 2) clinical assistant, 3) dentist, 4) physician. The clinicians questionnaires could point out the results of drug - patient presentation computerized clinical decision support.
Source of differential diagnosis of oral medicine problems that relate to medical problems are:
1) diagnosispro
2) isabelhealthcare
3) Dxplain
The following are referenced to diagnosispro
Sore mouth differential diagnosis:
http://en.diagnosispro.com/differential_diagnosis-for/sore-painful-mouth/24455-154-1.html
toxic epidermal necrolysis is in the differential diagnosis of sore mouth
audio digest emergency medicine has had a discussion of a legal case where a resident missed the diagnosis of Stevens Johnson Syndrome - Toxic Epidermal Lysis when a patient presented with: :” doc I’ve got a sore mouth; it feels like I’ve got blisters in my mouth”
See also:
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Crit Care Med. 2011 Jun;39(6):1521-32. doi: 10.1097/CCM.0b013e31821201ed.
Toxic epidermal necrolysis and Stevens-Johnson syndrome: a review.
Gerull R, Nelle M, Schaible T.
Source
Department of Neonatology, Inselspital Bern, Bern, Switzerland. [email protected]
Abstract
OBJECTIVES:
The aims of this review are to summarize the definitions, causes, and clinical course as well as the current understanding of the genetic background, mechanism of disease, and therapy of toxic epidermal necrolysis and Stevens-Johnson syndrome.
DATA SOURCES:
PubMed was searched using the terms toxic epidermal necrolysis, Stevens-Johnson syndrome, drug toxicity, drug interaction, and skin diseases.
DATA SYNTHESIS:
Toxic epidermal necrolysis and Stevens-Johnson syndrome are acute inflammatory skin reactions. The onset is usually triggered by infections of the upper respiratory tract or by preceding medication, among which nonsteroidal anti-inflammatory agents, antibiotics, and anticonvulsants are the most common triggers. Initially the diseases present with unspecific symptoms, followed by more or less extensive blistering and shedding of the skin. Complete death of the epidermis leads to sloughing similar to that seen in large burns. Toxic epidermal necrolysis is the most severe form of drug-induced skin reaction and includes denudation of >30% of total body surface area. Stevens-Johnson syndrome affects <10%, whereas involvement of 10%-30% of body surface area is called Stevens-Johnson syndrome/toxic epidermal necrolysis overlap. Besides the skin, mucous membranes such as oral, genital, anal, nasal, and conjunctival mucosa are frequently involved in toxic epidermal necrolysis and Stevens-Johnson syndrome. Toxic epidermal necrolysis is associated with a significant mortality of 30%-50% and long-term sequelae. Treatment includes early admission to a burn unit, where treatment with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. The mechanism of disease is not completely understood, but immunologic mechanisms, cytotoxic reactions, and delayed hypersensitivity seem to be involved.
CONCLUSION:
Profound knowledge of exfoliative skin diseases is needed to improve therapy and outcome of these life-threatening illnesses.
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One could point out the lack of patient education to see their doctor / dentist IF they are on a medicine that causes toxic epidermal necrolysis AND has the sensation of soreness in their mouth.
One could point out the lack of drug - clinical presentation interaction decision support in current EMR's
One could point out that a drug might have been started by an "outside provider of care" and that it could only be available if there was an intersection between the outside provider of care and an "integrated HIE"
An integrated HIE can help prevent "missed opportunities" to make an early diagnosis in whcih can be a devastating disorder, toxic epidermal necrolysis / Stevens Johnson Syndrome
Charles Beauchamp MD, PhD
Dr. Powell:
It is important to develop use-cases concerning the value of the participation of the dentist and the medical team in the early diagnosis of devastating disorders that have oral presentations.
The list of these disorders could start with differential diagnosis lists for:
1) sore mouth
2) oral lesion
For facilitating an even more perfect “integrated care model” with the assistance of an “integration” of HIE, EMR and triage clinical note, it would be opportune to consider including ophtalmic presentations such as are graphed for ophthalmic ADR’s on debategraph: http://www.debategraph.org or http://debategraph.org Go to debategraph, click on Search (you do not have to register) for “ADRs”, look under the first list of results for “Examples of Ophthalmic ADRs” and see a graph that I created on that site.
It is, BTW, potentially possilbe to get input from multiple clinicians/dentists/opthalmologists/opticians concerning early diagnosis issues by using debategraph