Dr. Neal Patel was the keynote speaker at the Central Illinois Health Information Exchange (CIHIE) Summit: Patient Care and Connectivity, a medical conference held in East Peoria on Sept. 21.

The days of the “Dr. House” physician are over.

“Dr. House is supposed to be this mastermind that is able to assimilate all this information and come out with a master synthesis and decision,” said Dr. Neal Patel, speaking of the title character of the television show House. “That was all very well and good in the old way of practicing medicine. But the problem is that we have cognitive overload now.”

This cognitive overload includes more than 900,000 biomedical articles per year, 10,000 randomized controlled trials per year, thousands of evidence based guidelines, 20,000 genes, and 1,700 disease associated mutations, not to mention the number of patients.

“We need tools when we are in those situations,” said Patel, Chief Informatics Officer at Vanderbilt University Medical Center in Nashville, Tenn. Patel spoke to the audience of the Central Illinois Health Information Exchange (CIHIE) Summit: Patient Care and Connectivity, a medical conference held in East Peoria on Sept. 21. See the presentations here.

Information has been called the “lifeblood of medicine” by David Blumenthal, former National Coordinator of Health Information Technology for the US Department of Health and Human Services.

“Right now, if you look at the financial system, you can stick your ATM card in any machine in the world and access your financial information,” said Joy Duling, Interim Executive Director of CIHIE. “I believe healthcare will get there.”

The journey starts with regional Health Information Exchanges (HIEs). HIEs are networks that connect participating providers, allowing for easy access of complete electronic medical records of participating patients. It is hoped that regional HIEs will eventually connect together.

Vanderbilt stumbled upon the HIE concept in opening electronic transfer of information within the hospital - across lab, radiology, pharmacy, and clinical departments. What is so consistent with the HIE (across multiple providers) concept is that the data does not reside in the same system. The connecting software simply retrieves this data and assembles the information into a format that makes sense for a given workflow.

CIHIE is nearing launch. Two years ago, Illinois was ranked 49^th for HIE readiness. Currently, Vanderbilt is working toward their own regional HIE.

“We are on the same journey with you,” said Patel. “So you now are at the lead of the pack.”

CIHIE planners have soaked up wisdom from other organizations and Vanderbilt offers a wealth of lessons learned from their early start in health IT.

Don’t make me think

Patel has helped build Vanderbilt’s health IT with a simple philosophy: “It has to work and make my life easier.” 

“A lot of folks want us in healthcare to be a lot like the airline industry,” Patel said, showing an image of a cockpit with a complex mess of dials and gauges. “Is this the model for good patient care?”

New technology always faces a challenging implementation among those resistant to change. According to Patel, many fear “screwing it up”. Surveys say most people arrange a wake-up call when staying at a hotel because they fear “screwing up” the unfamiliar clock radio and oversleeping.

Simplicity is key. Patel’s blueprint for Vanderbilt’s system follows the same principles as the toaster oven.

In The Design of Everyday Things, Donald Norman outlines the strategies for effective system design for such things as toaster ovens, airline seats, and auto dashboards. The strategies include:

1. Make things visible
2. Simplify the structure of tasks
3. Intuitive design
4. Make it hard to do the wrong thing
5. Make it easy to recover from a mistake
6. Standardize processes to reduce opportunities for errors

Dr. David Lawrance, Medical Director at the University of Illinois McKinley Health Center, asks a question during the Q & A portion of the conference.

 “Google makes it really easy for you,” Patel said. “They give you one blank white page and one box. Piece of cake. That was by design. It was not because they were lazy. We’ve seen a lot of search engines screw it up by trying to be too smart.”

Possibilities

Health IT and HIEs hold the potential to go beyond the obvious benefit of connecting islands and gathering the scattered history of a patient, saving time and reducing duplication. The idea is not just more information, but the right information.

“We want the right data at the right time so the F-16 can land on the aircraft carrier and not have to look at 15,000 dials and miss the deck,” Patel said.

Like the banking industry, healthcare is working to automate processes such as charting and free up more time for the physician to talk with the patient. However, automation should not be the sole focus, according to Patel.

“(Automation) doesn’t necessarily help us make good decisions,” Patel said, using the ATM card as an example of computerized automation. “It took a lot of willpower for me not to put my ATM card into the slot machine at the casino across the street last night. There is no decision support coming back saying ‘Patel, you shouldn’t do this.’”

Cognitive overload may very well spell the death of the “Dr. House” physician as the focus shifts to reducing the reliance on memory. Modern physicians can tap into digitized libraries of current evidence or decision supports to treat the patient in front of them. These systems embed valuable expertise with the frontline doctor who may have only a few years’ experience and a few moments to make a medical decision.

Electronic health records turn patient information into actionable data that can grade staff performance at the time of delivery, as opposed to after the fact when no alternative plan can be made to fix the problem. In many cases, providers know what should be done. The problem is that too often it simply doesn’t get done.

“We are making errors in our system. This is not because we have bad clinicians or bad bedside personnel. Our system is loaded with so many things to do and so much information to look at,” said Patel. Health IT can help take the edge off the overload.

For example, Vanderbilt used data in an effort to reduce ventilator associated pneumonia, an infection associated with prolonged use of mechanical ventilation. As with many efforts to tackle infection in hospitals, Vanderbilt instituted a checklist of tasks for staff to work through to tend to the patient.

Every time a checklist item is accomplished, it is recorded and displayed in the system. The staff can easily see how many items have been checked off for each patient, represented with the colors red, yellow, and green. The staff worked together to keep patients in the green. When all requirements were met, ventilator associated pneumonia rates plummeted.

Beyond direct patient care, HIEs will create unprecedented data on populations, allowing for experts to get a bird’s-eye view of health trends for research.

Before quality data can be abstracted, however, the infrastructure must be established and there needs to be a lot of data available. The power of connectivity will be a slow reveal as data flowing within the HIE becomes richer.

“Everyone talks about a ‘go live’ and it sounds like a light switch that you are going to flip and all of sudden the HIE is going to be live. This is not like that,” Duling said. “I describe it as a dimmer switch, that starts very low and you turn it up, up, up and it gradually gets brighter.”