Monday, September 14, 2009

"A cadre of people who understand the science"

Here is a fascinating, spot-on exchange regarding biomedical information science between Bill Moyers on PBS and the new President of Dartmouth College Dr. Jim Yong Kim (link). My comments in [red italics]:

DR. JIM YONG KIM: My own particular take on it is that I think for many, many years, we've been working under the fantasy that if we come up with new drugs and new treatments, we're done. 

The rest of the system will take care of itself. In my view, the rocket science in health and health care is how we deliver it. And unfortunately, there's not a single medical school that I know of that actually teaches the delivery of health care as one of the essential sciences. 

In other words, what we've learned about organizations is that it is very difficult to get a complex organization, a group of people, to work consistently toward a goal. In the business world, if you don't do it well, the market gets rid of you. You go out of business. But many hospitals executing very poorly persist for a very, very long time. So my own view of it is that we have to rethink fundamentally the kind of research we do and the kind of people we educate, so that they'll think about the complexity of delivery as a topic that we can take on and study and learn about as a science. [And possess a broad and deep enough background to understand these issues at very fine-grained levels, which in my opinion includes a rigorous scientific background to start with - ed.]

BILL MOYERS: What do you mean, complexity of delivery?

DR. JIM YONG KIM: Well, just think about a single patient. So a patient comes into the hospital. There's a judgment made the minute that patient walks into the emergency room about how sick that person is. And then there are relays of information from the triage nurse to the physician, from the physician to the other physician, who comes on the shift. 

From them to the ward team, that takes over that patient. There's so many just transfers of information. You know, we haven't looked at that transfer of information the way that, for example, Southwest Airlines has. Apparently they do it better than any other company in the world. [I would add that the nature of such transfers and the complexity of the information itself is far simpler in the Airline business than in medicine, so this is not the best analogy - ed.]

BILL MOYERS: Computers?

DR. JIM YONG KIM: No, they have taken seriously the human science of how you transfer simple information from one person to the next. [Note how Dr. Yong Kim wisely dismisses computers as the solution, in favor of people. He does not suffer the syndrome of inappropriate overconfidence in computers - ed.] And in medical school, and in the hospitals that I've worked in, we've done it ad hoc. Sometimes we do it well. Sometimes we don't do it well. But what we know is that transfer of information is critical. Now to me, again, that's the rocket science. That's the human rocket science of how you make health care systems work well 

What we need now is a whole new cadre of people who understand the science, who really are committed to patient care. But then also think about how to make those human systems work effectively. We've been calling it, aspirationally, the science of health care delivery. And we do it at Dartmouth. 

30 years ago, one of our great faculty members, Jack Wennberg, started asking a pretty simple question. Why is there variation, for example, in the number of children who get their tonsils taken out, between one county in Vermont versus another? 'Cause one of his children was in school at one place. Another of his children were in the school in another place. 

And in one place, almost everyone had their tonsils out. And in another place, almost no one did. And of course, he found that there happened to be a doctor there who liked to take tonsils out and benefited from it. And he kept asking this question, you know, outcome variation. He called it the evaluative clinical sciences. And I think that's really the forerunner to what we're talking about in terms of the science of--


DR. JIM YONG KIM: --health care delivery.

I can add that part of that "cadre of people who understand the [information transfer] science" exists, in the form of Medical Informatics specialists (e.g., as produced by these organizations and many others in the U.S. and worldwide). Understanding the complexities of information transfer also calls for understanding the clinical environment and, in my view, the biomedical science as well.

However, you might never know this via reading statements from some of the non-clinical HIT leaders such as "computers enable complexity" [as opposed to well-trained and experienced medical experts - ed.]

It is indeed unfortunate that most hospital ads seeking Medical Informatics expertise are for "Director level" positions with little control of resources, i.e., they are "Director of Nothing" roles, diluting the contributions of such experts in the highly politicized and territorial environment of a hospital IT department.

Unfortunately, most in hospital IT today are just repackaged business computing personnel of a management information systems (MIS) background whose lack of knowledge of these topics or cavalier attitudes about them has actually harmed the progression of health IT as a practical tool, as I've profusely documented on this blog (e.g., here) and at my educational HIT site here.

An example of just how difficult the "rocket science" of information transfer can be is this, from a psychiatrist:

I work on an acute psychiatric inpatient unit. We see each patient on rounds each day, write a note in the chart each day and bill each day. However, the nature of psychiatric units are that patients wander freely around the unit. Consequently, whenever I walk onto the unit, I often have interactions with one or more patients, just in the short distance between the door and the nursing station. Some of those are brief but still give me a sense of how they are doing at that point, other interactions involve brief questions from the patients, still others involve walking to the patients' room and sitting down to discuss a particular issue in greater depth with the patient and/or family.

Each of these involves a direct patient to clinician interaction and require that I exercise judgment (often a judgment that they're doing OK). Yet none of these are billable interactions and most are not documented.

I was aware of this from my own medical school clerkship in psych. The fact that these valuable interactions are largely undocumented (except in the physician's gray matter) merely shows that modeling the real world of healthcare into neat, tidy little containers of information is harder than modeling the inventory and sale of widgets, due to the complexities of healthcare. One more of those "EHR as panacea" exceptions ...

(And even the modeling of widgets isn't always done well. I went to my local MicroCenter last week seeking an EIDE-to-USB hard drive enclosure, to use the orphaned 80Gb hard drive I upgraded in my Mac Mini to serve as a Time Machine backup drive. Their inventory system showed they had a dozen on hand; nobody could find them, anywhere. A week later - yesterday - the same situation prevailed.)

Finally, a quibble. Later in the exchange Dr. Yong Kim makes the statement that "Right now, the physicians who are running these hospitals have never been trained. Most of them have never been trained in system thinking, in strategy, in management."

As most hospitals are not run by physicians, I'd have to disagree with that statement. It perhaps should be redirected to the non-medical businesspeople in the C-suite and on the hospital Boards who do run hospitals, to which I'd add "who have never been trained in biomedicine."

-- SS


Anonymous said...

It's not unusual for those running the hospital to be very different from those in the C-suite or the boardroom.

Anonymous said...

Digitizing ambiguity and judgment destroys both vitally important components of medical care.

This is one of many reasons why HIT devices have been found to be cognitively disruptive and inherently error generating.

MedInformaticsMD said...

Anonymous said:

"It's not unusual for those running the hospital to be very different from those in the C-suite or the boardroom."

I don't think so. Remember the golden rule: he who controls the gold, makes the rules.

Further unqualified statements that make little sense will simply be deleted. If you want to make such statements, give specific examples.

-- SS