{"id":2632,"date":"2017-05-01T18:23:49","date_gmt":"2017-05-01T17:23:49","guid":{"rendered":"http:\/\/jodischneider.com\/blog\/?p=2632"},"modified":"2017-05-02T01:19:44","modified_gmt":"2017-05-02T00:19:44","slug":"david-liebovitz-achieving-care-transformation-by-infusing-electronic-health-records-with-wisdom","status":"publish","type":"post","link":"https:\/\/jodischneider.com\/blog\/2017\/05\/01\/david-liebovitz-achieving-care-transformation-by-infusing-electronic-health-records-with-wisdom\/","title":{"rendered":"David Liebovitz: Achieving Care transformation by Infusing Electronic Health Records with Wisdom"},"content":{"rendered":"<p>Today I am at the <a href=\"https:\/\/healthdataanalytics.illinois.edu\/program\/\">Health Data Analytics summit<\/a>. The title of the keynote talk is Achieving Care transformation by Infusing Electronic Health Records with Wisdom. It&#8217;s a delight to hear from a medical informaticist: <a href=\"https:\/\/newfaculty.uchicago.edu\/page\/David-Liebovitz\">David M. Liebovitz<\/a> (<a href=\"https:\/\/scholar.google.com\/citations?user=h18Z1NQAAAAJ&amp;hl=en&amp;oi=ao\">publications in Google Scholar<\/a>), MD, FACP, Chief Medical Information Officer, The University of Chicago. He graduated from University of Illinois in electrical engineering, making this a timely talk as the engineering-focused\u00a0<a href=\"https:\/\/medicine.illinois.edu\">Carle Illinois College of Medicine<\/a>\u00a0gets going.<\/p>\n<p>David Liebovitz started with a discussion of the <strong>data problems<\/strong> &#8212; problem lists, medication lists, family history, rules, results, notes &#8212; which will be familiar to anyone using EHRs or working with EHR data. He draws attention also to the human problems &#8212; both in terms of provider &#8220;readiness&#8221; (e.g. their vision for population-level health) as well as about &#8220;current expectations&#8221;. (An example of such an expectation is a &#8220;main clinician satisfier&#8221; he closed with: U Chicago is about to turn on outbound faxing from the EHR!) He mentioned also the importance of resilience.<\/p>\n<p>He mentioned customizing systems as a risk when the vendor makes upstream changes (this is not unique to healthcare but a threat to innovation and experimentation with information systems in other industries.) Still,<strong> in managing the EHR, there is continual optimization<\/strong>, scored based on a number of factors. He mentioned:<\/p>\n<ul>\n<li>Safety<\/li>\n<li>Quality\/patient experience<\/li>\n<li>Regulatory\/legal<\/li>\n<li>Financial<\/li>\n<li>Usability\/productivity<\/li>\n<li>Availability of alternative solutions<\/li>\n<\/ul>\n<p>As well as weighting for old requests.<\/p>\n<p>He emphasized the <strong>complexity of healthcare<\/strong> in several ways:<\/p>\n<ul>\n<li>&#8220;Nobody knew that healthcare could be so complicated.&#8221; &#8211; POTUS<\/li>\n<li>Showing the <a href=\"https:\/\/www.cms.gov\/Medicare\/Medicare-Fee-for-Service-Payment\/AcuteInpatientPPS\/Readmissions-Reduction-Program.html\">Medicare readmissions adjustment factors<\/a><\/li>\n<li>Pharmacy pricing, an image (showing kickbacks among other things) from <a href=\"https:\/\/www.nap.edu\/read\/12750\/chapter\/8#218\">&#8220;Prices That Are Too High&#8221;, Chapter 5<\/a>,\u00a0<em>The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary<\/em> (2010) \u00a0National Academies Press\u00a0doi:<a href=\"http:\/\/dx.doi.org\/10.17226\/12750\">10.17226\/12750<\/a><\/li>\n<\/ul>\n<div id=\"attachment_2634\" style=\"width: 501px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/www.nap.edu\/openbook\/12750\/xhtml\/images\/p2001c7c5g189001.jpg#.WQdGvqBakTM.link\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-2634\" class=\"size-full wp-image-2634\" src=\"https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/Prices-that-are-too-high.jpg\" alt=\"complexity of drug purchasing\" width=\"491\" height=\"344\" srcset=\"https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/Prices-that-are-too-high.jpg 491w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/Prices-that-are-too-high-300x210.jpg 300w\" sizes=\"auto, (max-width: 491px) 100vw, 491px\" \/><\/a><p id=\"caption-attachment-2634\" class=\"wp-caption-text\">An image from &#8220;Prices That Are Too High&#8221;, Chapter 5, The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary (2010)<\/p><\/div>\n<ul>\n<li>Icosystem&#8217;s diagram of the complexity of the healthcare system<\/li>\n<\/ul>\n<div style=\"width: 1366px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full\" src=\"http:\/\/www.icosystem.com\/site\/wp-content\/uploads\/2013\/05\/healthcare_system_chart_1356x1049.jpeg\" alt=\"Complexity of the healthcare system\" width=\"1356\" height=\"1049\" \/><p class=\"wp-caption-text\">Icosystem &#8211; complexity of the healthcare system<\/p><\/div>\n<ul>\n<li>Another complexity is the\u00a0<strong>modest impact of medical care compared to other factors<\/strong>\n<ul>\n<li>such as\u00a0the\u00a0<strong>impact of socioeconomic and political context<\/strong> on equity in health and well-being (see the WHO image below).<\/li>\n<li>For instance, there is a<strong> large impact of\u00a0health behaviors<\/strong>, which &#8220;happen in larger social contexts.&#8221; (See the <a href=\"http:\/\/www.healthaffairs.org\/healthpolicybriefs\/brief.php?brief_id=123\">Relative Contribution of Multiple Determinants to Health<\/a>,\u00a0August 21, 2014, Health Policy Briefs)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<div id=\"attachment_2636\" style=\"width: 1034px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/www.who.int\/sdhconference\/resources\/ConceptualframeworkforactiononSDH_eng.pdf\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-2636\" class=\"wp-image-2636 size-large\" src=\"https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/social-determinants-health-1024x660.png\" alt=\"Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice).\" width=\"1024\" height=\"660\" srcset=\"https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/social-determinants-health-1024x660.png 1024w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/social-determinants-health-300x193.png 300w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/social-determinants-health-768x495.png 768w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/social-determinants-health.png 2030w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/a><p id=\"caption-attachment-2636\" class=\"wp-caption-text\"><a href=\"http:\/\/www.who.int\/sdhconference\/resources\/ConceptualframeworkforactiononSDH_eng.pdf\">Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice)<\/a>.<\/p><\/div>\n<p>Given this complexity, David\u00a0Liebovitz stresses that <strong>we need to start with the right model<\/strong>, &#8220;simultaneously improving population health, improving the patient experience of care, and reducing per capita cost&#8221;. (See <a href=\"http:\/\/www.ihi.org\/resources\/Pages\/IHIWhitePapers\/AGuidetoMeasuringTripleAim.aspx\">Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012<\/a>).<\/p>\n<div id=\"attachment_2635\" style=\"width: 710px\" class=\"wp-caption alignnone\"><a href=\"http:\/\/www.ihi.org\/resources\/Pages\/IHIWhitePapers\/AGuidetoMeasuringTripleAim.aspx\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-2635\" class=\"wp-image-2635\" src=\"https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/IHI-tripleaims-1024x860.png\" alt=\"triple aims to measure healthcare improvement\" width=\"700\" height=\"588\" srcset=\"https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/IHI-tripleaims-1024x860.png 1024w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/IHI-tripleaims-300x252.png 300w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/IHI-tripleaims-768x645.png 768w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/IHI-tripleaims.png 1614w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><p id=\"caption-attachment-2635\" class=\"wp-caption-text\">Table 1 from Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012.<\/p><\/div>\n<p>Given the modest impact of medical care, and of data, he suggests that we should\u00a0choose the right outcomes.<\/p>\n<p>David\u00a0Liebovitz says that &#8220;not enough attention has been paid to usability&#8221;; I completely agree and suggest\u00a0that information scientists, human factors engineeers, and cognitive ergonomists help mainstream medical informaticists fill this gap. He put up\u00a0Jakob Nielsen&#8217;s\u00a0<a href=\"https:\/\/www.nngroup.com\/articles\/ten-usability-heuristics\/\">10 usability heuristics for user interface design<\/a>\u00a0A vivid example is whether a patient&#8217;s\u00a0resuscitation preferences\u00a0are shown (which seems to depend on the particular EHR screen): the system doesn&#8217;t highlight where we are in the system. For providers, he says user control and freedom are very important. He suggests that\u00a0there are only a few key tasks.\u00a0A\u00a0provider\u00a0should be able to do ANY of these things wherever they\u00a0are in the chart:<\/p>\n<ul>\n<li>put a note<\/li>\n<li>order something<\/li>\n<li>send a message<\/li>\n<\/ul>\n<p>Similarly, EHR should support\u00a0recognition (&#8220;how do I admit a patient again?&#8221;) rather than requiring recall.<\/p>\n<p>Meanwhile, on the decision support side he highlights the (well-known) problems around interruptions by saying that speed is everything and\u00a0changing direction is much easier than stopping. Here he draws on some of his own work, describing what he calls a &#8220;diagnostic process aware workflow&#8221;<\/p>\n<div id=\"attachment_2637\" style=\"width: 710px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/doi.org\/10.1515\/dx-2014-0070\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-2637\" class=\"wp-image-2637\" src=\"https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/Liebovitz-Diagnosis-2015-1024x749.png\" alt=\"\" width=\"700\" height=\"512\" srcset=\"https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/Liebovitz-Diagnosis-2015-1024x749.png 1024w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/Liebovitz-Diagnosis-2015-300x219.png 300w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/Liebovitz-Diagnosis-2015-768x562.png 768w, https:\/\/jodischneider.com\/blog\/wp-content\/uploads\/2017\/05\/Liebovitz-Diagnosis-2015.png 1994w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><p id=\"caption-attachment-2637\" class=\"wp-caption-text\">David Liebovitz. Next steps for electronic health records to improve the diagnostic process.\u00a0Diagnosis 2015 2(2) 111-116. doi:10.1515\/dx-2014-0070<\/p><\/div>\n<p>Can we predict X better?\u00a0Yes, he says (for instance pointing to <a href=\"https:\/\/doi.org\/10.1371\/journal.pone.0174944.t003\">Table 3 of &#8220;Can machine-learning improve cardiovascular risk prediction using routine clinical data?&#8221;<\/a> and its machine learning analysis of over 300,000 patients, based on variables chosen from previous guidelines and\u00a0expert-informed selection&#8211;generating further support for aspects such as\u00a0aloneness, access to resources, socio-economic status).\u00a0But what&#8217;s really needed, he says, is to:<\/p>\n<ul>\n<li>Predict the best next medical step, iteratively<\/li>\n<li>Predict the best next lifestyle step, iteratively<\/li>\n<li>(And what to do about genes and epigenetic measures?)<\/li>\n<\/ul>\n<p>He shows an image of &#8220;All of our planes in the air&#8221; from\u00a0flightaware, drawing the analogy that we want to work on\u00a0&#8220;optimal patient trajectories&#8221; &#8212; predicting what are the &#8220;turbulent events&#8221; to avoid&#8221;. This is not without challenges. He points to three:<\/p>\n<ul>\n<li>Data privacy (He suggests <a href=\"http:\/\/doi.org\/10.1007\/s12553-017-0179-1\">Google DeepMind and healthcare in an age of algorithms. Powles, J. &amp; Hodson, H. Health Technol. (2017). doi:10.1007\/s12553-017-0179-1<\/a><\/li>\n<li>Two sorts of mismatches between the current situation and where we want to go:\n<ul>\n<li>For instance the source of data being from finance<\/li>\n<li>Certain basic\u00a0current clinician needs \u00a0(e.g. that a main clinician satisfier is that UChicago is soon to turn on outbound faxing from their\u00a0EHR &#8212; and that an ongoing source of dissatisfaction: managing volume of inbound faxes.)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>He closes suggesting that we:<\/p>\n<ul>\n<li>Finish the basics<\/li>\n<li>Address key slices of the spectrum<\/li>\n<li>Descriptive\/prescriptive<\/li>\n<li>Begin the prescriptive journey: impact one trajectory at a time.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Today I am at the Health Data Analytics summit. The title of the keynote talk is Achieving Care transformation by Infusing Electronic Health Records with Wisdom. It&#8217;s a delight to hear from a medical informaticist: David M. Liebovitz (publications in Google Scholar), MD, FACP, Chief Medical Information Officer, The University of Chicago. He graduated from [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[85],"tags":[640,641,642,639],"class_list":["post-2632","post","type-post","status-publish","format-standard","hentry","category-information-ecosystem","tag-data-analytics","tag-electronic-health-records","tag-healthcare-systems","tag-medical-informatics"],"_links":{"self":[{"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/posts\/2632","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/comments?post=2632"}],"version-history":[{"count":5,"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/posts\/2632\/revisions"}],"predecessor-version":[{"id":2642,"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/posts\/2632\/revisions\/2642"}],"wp:attachment":[{"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/media?parent=2632"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/categories?post=2632"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/jodischneider.com\/blog\/wp-json\/wp\/v2\/tags?post=2632"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}