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Blind Spots Can Kill . . . Patients

December 21, 2010
by Joe Bormel
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Having access to the right, relevant information at the right time is key

Blindspots–Where Does Healthcare Information Technology Help?

Most of us who work in clinical healthcare information technology (HCIT) share a basic vision. This vision can be reduced down to a couple of extremely basic, fairly self-evident, non-arguable propositions.

First, if we patients, family members, doctors, nurses, and those other folks we rely on always had complete, accurate, up-to-date, and relevant information, our healthcare system would be much better. And second, having that information would inexorably lead to better decisions and therefore better care.

Invisibly built into the vision are a few painful assumptions including: • The technology is affordable and fast-enough, i.e. pretty much instantaneous. • The people issues are straight-forward and non-blocking such as an interest in and willingness to change, and to be trainable concerning arbitrarily complex systems and processes. • All of the major stakeholders agree on the explicit definition of what is meant by "our healthcare system would be much better."
Our vision on the third point above is that we can, given the will, time and money, transcend or otherwise overcome the limits implied by these assumptions.

For the sake of this discussion, let's assert that our vision is just simply true, that the information is good, it leads to better care, and all that's missing is the deployment of readily available, affordable technology.

In my next few blog posts, along with comments from conversations with a few friends, we're going to explore a series of subtle issues, the blind spots, associated with going from always having access to the right and relevant information at the right time, to the necessary interpretation and translation actions that enable us to exploit that information. Here are a few of the bigger obstacles, landmarks and questions we'll encounter during our journey:
1. Patient safety and medical diagnostics error literature has recognized more than 30 biases and fallacies that lead all of us, including doctors, to take correct information and come to incorrect conclusions. (See my Swan and Turkey blog post for a simple, brief example.)
2. Although potentially rational, humans do not act perfectly rational, nor should they. A Nobel Prize winning economist, Herbert Simon has more so say there.
3. We use conscious thinking and reasoning, as well as semiconscious "thinking" to get to many important conclusions. There are a wide variety of important issues in semiconscious thinking that won't necessarily be improved simply by improving the delivery of information. One term for a way computers might help is called decision support. Other terms that incorporate the concept of guidance include workflows and checklists.
4. Along with semi-consciousness is the notion that at least some of the skills and knowledge to use information are readily teachable. The question is, can information technology play a role in all forms of just-in-time teaching and learning?
5. Lastly, in our journey to better care, are there relevant differences about how generalists use information versus sub-specialists, e.g. cardiologists or infectious disease physicians? If there are, when if ever does better care result from seeing one or the other first to get the right diagnostic and therapeutic interventions? What testing should a patient get before seeing either or both for clear cut problems like blood appearing in urine?
Simply delivering relevant information reliably, while important, is only one contribution of healthcare information technology. As we pour billions of dollars into using HCIT to help us attain the evolving staged definitions of Meaningful Use, this might be a good time to explore the sometimes complex journey to better care.
Enjoy the ride, but watch out for blind spots!
Joe Bormel, M.D., MPH
CMO & VP, QuadraMed




Thanks Frank.

To your point, there are several articles in the just released Health Affairs. I haven't read the full articles yet, but abstracts suggest that analysis of Accountable Care Organization incentives can cause shifts with resulting increases in fee-for-services utilization rates. Complex systems can and often do give rise to complex behaviors.

Great can't wait for the rest. How's this for a blind spot. In the MU regs and citeria a specialist doc has to meet the MU for vaccine info. Now let me see, when was the last time I went to an opthamologist for that flu shot ???
To be fair the testing bodies are granting exemptions on this one now after getting a bunch of complaints.
Frank Poggio
The Kelzon Group

Dr. Bormel,
This is an interesting topic. I'm very pleased that you'll be writing a series of posts about it, as I think this is far to complicated to cover in a single blog.

Addressing the question you ask in your fourth point, my answer is not at this time. The technology is not yet developed to the degree necessary to cover all of the information necessary to ensure success. In this case, the blind spots would be created by "the blind leading the blind."

And looking at your questions in point five, I believe there is a significant difference between how the two groups process and interpret information. Sub-specialists, by nature, must have a more narrow view. To your second question, in the majority of cases, my initial thinking is that the generalist should be seen to determine what, if any, tests are necessary in the first place.

I look forward to your series on this subject.

Doc Benjamin

Part Two continues here:

Thanks for your comment Doc Benjamin.

Regarding your comment on just-in-time learning, I had a relevant experience yesterday. I woke up to find that my smart phone upgraded itself, over the air, unattended and not asking me, to the latest version of it's operating system. Several controls and applications changed subtly, including new colors, new icons, and some new functionality. Several hours later, I went to place a call or use the GPS, I cannot remember which, and I was offered to watch a brief video describing the new voice control functions. It was time for a little break, so I watched, and voila, just-in-time learning. I immediately started using some of the new functionality. No manual. No peer endorsements, no advertising, ... just a video, seamlessly embedded in the experience. Wow.

Thanks for picking up on the generalist and specialist point. You're right that the perspectives can have impact that we sometimes don't realize.

Thanks for your kind words. Stay tuned.