Don E. Detmer, MD, MAPresident & CEO, American Medical Informatics Association

Prof. Med. Education, University of Virginia

__________________________Hospital Authority Annual Meeting

8 May 2006Hong Kong

Harnessing Information Technology for Clinical Care:Assuring Value in Health Care

through Informatics

American Medical Informatics Associationdetmer@amia.org; http://www.amia.org

3500 members from 42 nations

Physicians; nurses; pharmacists; computer, information, & behavioral scientists; biomedical engineers; academic researchers; educators; IT managers; related corporate partners

http://www.amia.org

AMIA

- Cyril Chantler

Medicine used to be simple, ineffective, & relatively safe.

Now it is complex, effective, & potentially dangerous.

Craftsmanship Standard:

When all else fails, lower your standards.

- Roy Underhill, Woodwright’s Shop

“Does it ever bother you that health professionals call what we

do PRACTICE?”

The time lag which exists between the fact of change & the social & political understanding of what has happened.

- Henry Adams

Law of Acceleration of Changing Times

Achieving High Performance through Informatics.

How?

Make it easy to do it right.

- Dr. Brent James

Aim: System Transformation

from Costly, Inefficient, & Highly Variable Systems

to Systems that are equitable, safe, patient-centered, efficient, effective, & timely

91’-’99, the goal was Computer-based Patient Records (CPRs) for Clinicians.

’99-’01, it was Safety & CPRs.

’01-’06, it was Safety, Quality, & Electronic Health Records.Berner, Detmer, Simborg, JAMIA 12:3, 2005

From ’06 – Informatics to Assure Value

Information Technology ≠Informatics

• Information Technology is hardware & software.

• Informatics is IT plus change management, human-computer interactions, risk management, organizational behavior, workflow redesign, productivity improvements, safety, quality, etc.

The Reality

• Technology now develops very fast.• Technology diffusion is unpredictable &

doesn’t necessarily transfer appropriately. • Most health organisations change slowly.• Public policy struggles & generally fails to keep up.

Byte by Byte/Bit by Bitbyte = 8 bitskilobytes (103 ) = thousand bytesmegabytes (106 ) = million bytes gigabytes (109 ) = billion bytesterabytes (1012 ) = trillion bytes petabytes (1015 ) = thousand trillionexabytes (1018 ) = million trillion;

billion billion; quintillion

zebibyte (1024 exabytes)

= quite-a-bit

Information Big Bang

Hong Kong as a Global Leader• Robust HIT:

– Substantial Achievements since 1990– Continuing Aspirations

• 2003 SARS Epidemic –– Informatics Innovation & Continued Performance

under Extreme Condition

Well done is better than well said.

- Benjamin Franklin

Services Front EndDatabase EnginesEngines

Scheduling

CommunicationsWorkflow

Information ArchitectureInformation Architecture

GCD (forms) engine

Terminology engine

Imaging

Rules engineRules engine

Knowledge

Mes

sagi

ng a

nd in

tegr

atio

n

Pres

enta

tion

serv

er

SecuritySecurityUserAudit

Informatics-led Design

Informatics-led DesignOperational Operational

LayerLayer

ePRePR LayerLayer Source: Dr. William Ho

Hospital and HA Annual Plans

Head Office and Hospital

Suggestions

Head Office and Hospital

SuggestionsHA Strategic

PlanHA Strategic

Plan

Different Service Areas

Different Service Areas ConsultationConsultation

Needs Assessment and

Prioritized Schedule

Work Out Resource Allocation with

Hospitals

Work Out Resource Allocation with

Hospitals

Annual PlanAnnual Plan

COCCOC

Clinical Needs

Assessment

Clinical Needs

Assessment

CommunityCommunity

HA Strategic

Plan

HA Strategic

Plan

HGCHGC

GovtPolicyGovt

PolicySet Clinical Programs

HA ServicePrograms

Overall ServicesEffectivenes

Efficiency and Quality Indicators

Service Volume

Identify Appropriate Resources

Appropriate Allocation

to Hospitals+ ++

Source:

Dr. William Ho

2002 Hospital AuthorityEvolving Over Time

• Focused on automating paperwork & minimising duplication of data entry

• Targeted at doctors rather than all health professionals

• Linking departments rather than teams• Event rather than process-oriented• Showing effects of past necessary compromises to

gain adoption without clear migration strategies toward future system

Recommendations since 2002

• Health Needs Working Group needs to focus & determine definitions of the future system.

• Need closer integration of IT with rest of business – focus on use of information rather than the technology – use cross-functional teams to identify problems, recommend, & implement solutions

• Pilot eHR with private sector – focus on potential benefits, seek flexibility

IT Capabilities

IT Capabilities

For internal use of HKHA only. © 2004 Gartner, Inc. and/or its affiliates.

All Rights Reserved.Page 12

HKHAExecutive Briefing 9 November 2004

consulting

Application Development Process Maturity

0.0

1.0

2.0

3.0

4.0

5.0Application Design

Build & Test

Finance & Governance

IT Capability

Measures & Metrics

Project Management

Skills

Sourcing Capabilities

User Requirements

Assessment Scale0 = Non

-Existent / Not Applicable

-

activity/processes are not applied at all.

1 = Informal-

2 = Documented-

3 = Formalized

-4 = Measured

5 = Leading

HA Results

>= 35% of Large IT Shops

MaturityTarget

Source:

Dr. William Ho

An idealist believes the short run doesn’t count. A cynic believes that the long run doesn’t matter. A realist believes that what is done or left undone in the short run determines the long run.

- Sidney J. Harris

Assuring Value in Clinical Settings 2006-2010

• Complete the Infrastructure• Enhance Clinical Decision Support

– Find Best Practices & Scale for General Users• Chronic Illness Management

• Change Management & Work Redesign• Miscellaneous

– Research, Education, – Other

• Paperless?

Complete the Infrastructure• Network All Care Sites

– Tie all Providers into the Health Information Infrastructure

• From Doctors to Care Teams – All Health Workers plus Citizens & Patients become real Partners on the Care Team

• Add Formal Education– Academicians– Clinicians– Citizen

• Add Academic Research & Development– Engineering– Health Sciences– Multidisciplinary Centers

Firewall

ePR Sharing with Private Sector

ePR Sharing with Private Sector

ePRFirewall

DM Zone

ePRsubset

HA

SecureToken

CMS

Patient key25438295

PrivateDoctor

Patient key25438295

Source:

Dr. William Ho

Essential Elements of 21st Century Health Care System

• Robust information infrastructure•Widespread use of evidence-based medicine•Aligned incentives & regulatory requirements• Workforce skilled in evidence-based medicine, IT,

& process improvement

IOM Health Professions Education: A Bridge to Quality 2003

Evidence-based medicine:The plural of anecdotes is not

data.

‘Smart’ Computer-based Health Records

“Just-in-time”“Just-for-me”

Knowledge Service with Strong Decision Support

Arguably, the first Education & Research Infrastructure Initiative of the USA NHIN

*AMIA for Dr. David Brailer, National Coordinator for Health IT – available June/July 2006

2006: Roadmap for Clinical Decision Support*

Clinical Decision Support Pathway• Capture Best Practice Experience – Local & Elsewhere

– Chronic Illness with Patient Educational ‘Applets’’• Pilot & then Implement at Naïve Sites• Allow Overrides, Collate Experience, Analyse as a

‘Reality Check’, Revise Guidelines, Repeat Process• Scale for General Use• Bank Guidelines on Accessible Website

– (Free for Download & Use)

Evidence-Based Adaptive Decision-Support Systems

• Evidence-based– Locally generated & from literature

• Decision-support systems/templates with ‘just-in-time’ knowledge service at ‘point of care’

• Adaptive – continuously studied & improved against care delivered & patient’s outcomes

- Sim, Gorman, Greenes et al, JAMIA 2001

• Support Clinically-related Knowledge Bases– Genomic / Personalized Healthcare– Affirming Decision support guidelines for EHRs– Assure Global Standards for Biomedical

Terminology & Classifications•Collaborate on Clinical Interface Terminologies

• Address Informatics Workforce Needs & Citizen/Patient Knowledge & Skills

Knowledge Management Issues Particularly Relevant for HK HA - 2012

•Real-time Information. There is a need to develop systems that can provide greatly improved monitoring, both of current disease trends, and also of critical current information in the literature.•Computable Research Outcomes. The results of clinical trials need to be convertible into a computable form. This will allow direct incorporation into decision support systems and more rapid dissemination to providers.•Impact of Informatics. Millions of dollars are being spent to deploy EHR systems. Because we lack good tools to measure the quality of care, we are unable to measure the impact of information systems. We need to develop these tools and apply them to measuring the impact of informatics.•Quality / Patient Safety. Quality and performance measurement programs are becoming increasingly common. Research is needed to validate the accuracy and reliability of these measures. •Software Assurance. As computer systems become an increasing part of the healthcare process, the risk for harm from software errors increases correspondingly. Research is needed to develop tools and processes to measure the accuracy and reliability of biomedical software.•Privacy / Security. The pooling and transport of health information provides huge opportunities for improvements in health research and health care, but it also creates large privacy risks. Methods need to be developed that support research across large populations, while maintaining adequate privacy.•Workflow. The area of workflow/business process management has been largely ignored in the health care domain. There is a need to be able to formally define workflows in computable terms. Research is needed to better define how health care teams function and how information technology changes that function. There is also a need to develop systems that enhance, rather than interrupt the workflow.•Social and Organizational Factors. Recent articles have confirmed that the implementation of health information technology involves much more that hardware and software. It impacts and is impacted by organizations practices and contexts. Understanding of these sociotechnical dynamics is still quite limited, and more research is needed.•Knowledge Structuring, Encoding and Management. In spite of work on structured vocabularies and ontologies, the ability to represent complex biomedical information in a computable form remains a major challenge. Research into the acquisition (such as NLP), representation (formal ontologies vs. fuzzy tagging), retrieval, and linking of knowledge (to clinical data and clinical context) is essential.•Interoperability. Although organizations are setting up networks to share data, standards and policies need significant improvement. Research is needed to determine the optimal level of granularity for sharing. Similarly, research is need to evaluate the impact of this sharing on processes and outcomes of care.•Decision Support. Despite multiple articles about the value of decision support, its broad applicability has been limited by two factors. First, there is insufficient understanding of how to develop, maintain, and integrate centralized decision support resources (either governmental or commercial). Second, existing decision support technology is not sufficiently context aware. As a result, recommendations often do not address the subtleties of individual patients and are overridden by practitioners.•Information Filtering and Aggregation. There is already more electronic medical literature than any human can absorb. As EHRs become common, there will be more information on every patient than a clinician can review and process. Research is needed to develop tools that can 1) succinctly summarize a patient past medical history from large volumes of data (including not only text, but also signal and image data); 2) mine data across large numbers of patients to identify important patterns; 3) access and summarize information from the clinical literature; 4) present appropriate information in a context-dependent way for the care of individual patients.•Education. Future clinicians will be distinguished more by their ability to manage electronic information resources, than by their internal fund of knowledge. Research is needed to determine the best way to train informatics-enabled clinicians. Similarly, study is needed to determine the best way to utilize the vast stores of electronic clinical data to improve the clinical education of clinicians.•Patient-centered Informatics. Informatics research as traditionally focused on clinicians. Research is needed to develop vocabularies, tools and user-interfaces that are appropriate for consumers and patients—and to evaluate the impact of these tools on health outcomes.•Human Computer Interaction. As increasing amounts of clinical data are generated, it becomes increasingly difficult for clinicians to review and synthesize it. Improved clinical displays are needed that help clinicians visualize, synthesize and comprehend clinical data quickly. Similarly, computer documentation of clinical care is slow and disruptive. Research is needed in interfaces that allow clinicians to easily and rapidly enter data in coded or structured form.•Clinical Research / Translational Informatics. Even though clinical research subjects are typically recruited from, and followed in, a clinical care environment, clinical and research information systems remain largely disjoint. More research is needed to make clinical systems “research aware”. Such systems would support the identification and recruitment of subjects, based on clinical data. They would support the collection of research data as part of the care process, rather than the current reentry approach. Data standards between research and clinical care need to be reconciled.•Cognition. Many of the reported issues with EHRs are not due solely to the system, or to the user, but due to the interaction between the two. Research is needed to better understand how decisions are made and how information technology changes those processes, for better or worse.

Research Challenges (Starren, et al)*

PATIENT Records –Clinic & Hospital

Records

PERSONALRecords –

Consumer & e-health records

PUBLIC HEALTH/POPULATION

Records –Community Records

Data Banks Repositories

Interlocking Computer-based Health Records (C3PRs)supported by knowledge (Research & Development / Education & Training with IT infrastructure)

First-classHealth Care

InfostructureKnowledge & Delivery

# 3

#1# 2

#4/5 Research &Development

# 4/5Education

&

Training

- Thomas Jefferson, 1807

The field of knowledge is the common property of all mankind.

An investment in knowledge always pays the best interest.

- Benjamin Franklin

1) Now: AMIA -10x10 program (http://www.amia.org/10x10/), &/or Nursing Informatics Programs

2) Coming: Medical Sub-certification in Applied Clinical Informatics

Know what you are doing. Support formal education/training in Applied Clinical Informatics.

The Future of Care is in using Informatics to Manage Change

supported by Information Technology

• Build Knowledgeable Teams• Reinvent Workflow • Integrate Innovations• Remove ‘Outdated’ Practices• Reduce Variation• Improve Safety/Quality while Reducing Costs• Manage the Base of Knowledge

• National Academies Study“Building a Better Delivery System”National Academy Press, 2005

The Future of Care is in using Informatics to Manage Change

supported by Information Technology

Hospital Authority might collaborate with University of Hong Kong’s Engineering School to develop Center for Innovative Practicewith Research, Development,Master’s Level Degrees

Formal Biomedical/Health Informatics Educational Development

Hospital Authority might collaborate with Hong Kong’s Medical/Nursing Schoolsto develop Master’s Level Degrees & Partner withAMIA’s 10x10 Programin Applied Clinical Informatics

The SARS Crisis

• Hospital Authority showed the world how a Health Information Infrastructure can link Public Health/Population with Patient Care Database

“Good judgement comes from bad experience.”

Firewall

eSARS ArchitectureeSARS Architecture

ePR

Data Warehouse

PMI

eSARS

Firewall

DM Zone

SARS-CTS

PMI

eSARS

Contacts

HKU

QuickTime?and aTIFF (LZW) decompressorare needed to see this picture. Dept Health

Police

HA

MIIDSS

Telephoneinterviews SARS-CCIS

HotspotAlert

CMS

eSARS

SituationReports

Labs

Source:

Dr. William Ho

Public Health/Population Informatics

• Hong Kong’s could easily become Asian Center of Excellence for Coursework in Public Health/Population Informatics*

* Consider AMIA10x10 Offerings

Public Health/Population Informatics

• Consumer (Citizen/Patient/Informal Caregivers) Education & Support

• The Patient has access to: – Appointments – Problem List – Medications – Allergies – Subset of test results – Demographic & Administrative Information– Educational materials

• The patient access is via secure internet with their permission. • Patients can request appointments, get meds mailed to them,

securely message their physician, etc. •The physician sees virtually all information; Some

departments such as addiction medicine is hidden.• [Transportable to another EHR system.]

Homer Chin, MD, KP

eiPHR (Integrated EMR/PHR) “The Gold Standard”

• Education & particularly Citizen/Patient Education is of growing interest & importance.

Nearly half of all American adults have difficulty understanding & acting upon health information.

Health Literacy (IOM 2000)

Review EU’s e-Citizen program & adapt it for use to engage serious health, computer, & numeracy literacy issues.Consider International Computer Driver’s License Offerings.

Support Web-based Programs that increase Citizen eiPHR

knowledge & skills.

2012 Questions for HA:

• Go Paper-free or Not?– Is It Either Good or Bad for Innovation &

Generating Value?• Create an International Informatics

Research & Development Center?

Successful Organisations; Change-friendly Systems

• Transparent Goals • Collaborate with Customers – internal &

external• Good at structuring & organising

knowledge• Adaptable• Allow decision-making near the level of

implementation

Leading Change in Complex Adaptive Systems

• Set simple rules & minimum specifications• Create conditions for system to evolve

over time• Create space for creativity & local actions

within the system• Called “Self-organisation”

Leadership – top, middle, front line - is crucial to success

LEADERS:• Know themselves• Know their environment

– culture, myths, aspirations, maintenance of identity• Communicate across boundaries intelligently

– translate content and style; directive language• Focus on points of action• Project the authority to model change• Act constructively

- Mario Andretti

Living in the Fast Lane:

If everything is under control, you are going too slow.

Don E. Detmer, MD, MA

Thank You & Best Wishes.

detmer@amia.org

http://www.amia.org

Generic Final Slide

Annual Symposium• Strong tutorial program

– Primer series– EHR series– Methods series– Selected topics series

• Late breaking policy sessions

David Bates, MD, Program Chair

AMIA Initiatives