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Relativity and Reality

November 19, 2008
by Joe Bormel
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Relativity and Reality
Correct diagnosis and treatment decisions require Rich IT

As I reflect on the Healthcare Informatics blogs over the last few months, half of the bloggers have shared stories of their family's experience with the healthcare delivery system. It is a profound experience when you become reliant on the services of the industry you strive to serve. The lessons shared have been personal and profound. They always highlighted the importance of an attitude of responsibility and caring.

The grace and sophistication to provide appropriate and comprehensive care, patiently delivered, may be impossible the way our systems are often constructed. I'll share one personal example involving my daughter, but similar things have happened to me and each member of my family, involving diagnostic testing and treatment selection. All of which have had good outcomes in the short term. No one, nor science, knows about the long term of course.

Underlying the desirable future state of care delivery is “Rich IT.” That is, documentation, ordering and economic accounting of care that is broadly based, beyond the antiquated but current model we have today.

My daughter required surgery to lengthen several muscles, which would correct a minor gait issue. We went to two experienced pediatric orthopedic surgeons. They were both confident with their recommendations, but the second opinion wasn't close to the first.

It turned out that an adequately precise diagnosis and assessment of treatment required something called a Gait lab. In our industry, that's called measurement of the current state and the outcome.

Gait labs are expensive to run and are generally not reimbursed; we were told that there weren't any within a hundred mile radius. For general clinical use, that's true.

We ultimately got a third surgical opinion that didn't match the first two, but was informed by a Gait lab assessment, by a surgeon who routinely does pre- and post-surgical assessments of his own work, and participates with a consortium of like-minded surgeons. (The kind of measurement discipline so well elaborated by fellow blogger, Doug Thompson.) We were feeling more confident, but we still had three very different surgical opinions. The fourth surgical opinion, also informed by a second Gait Lab, was a
hopeful and conservative subset of the three earlier opinions. We had the surgery last summer and my daughter is doing great.

My major point to this story is that half of the opinions were inadequately informed.

There are several great biographies of Einstein that I've read (Gleick, Isaacson). Each tells the relativity story in this way.
Two cities, hundreds of miles apart, each have a clock tower perfectly synchronized with the other. To an observer standing halfway between them, they sound and appear to strike noon simultaneously. When standing close to or next to either one, it appears to strike noon before the clock tower that is far away. In a very gross, human sense, the clock tower near you in this scenario is always ahead of the remote one. So the experience of the observer is not "truth," it's relative to where you're making your observation. You truly can't say observation is right without referencing where you were standing.
That’s relativity.

It’s messier than that in healthcare. In my example, each of the four surgeons was confident, from their perspective, that they were prescribing the best treatment. Two of them were clearly inadequately informed. Although IT alone can’t fix that, care coordination and delivery systems with competent policies embedded as content could fix the relativity problem.

I’ve recently had to deal, first hand, with similar relativity situations involving diagnostic radiology and, in another patient, management of hypercholesterolemia. Similar motif: dismissal of previous opinions and advice guided by relativity. A bias for overstating benefit and understating risk --- and conclusions that often didn’t adequately consider the patient situation and values (patient preferences).

I started this post with a graphic, which I believe summarizes the grand challenge that relativity places on HCIT.

Note the bottom left, labeled “1” – when there is medical certainty and social agreement around a medical decision, as there ultimately was for my daughter, policy and HCIT need to provide efficient, cost-effective coordination of appropriate care. Four opinions, redundant testing, delays and parental anguish are bad. Respecting the “relativity” built into each of the opinions, a process that served us in the past, is antiquated. Availability of resources, in our example, the Gait Lab, needs to be built into a rational care-coordination model.

Not addressed here are methods to do this, such as tight, internal Mayo or Geisinger referral models, or payment models like Medical Home. But whatever the method, the reality is that relativity needs to be recognized and put in its place, framed by Rich IT.

What do you think? Are our healthcare decisions so complex and personal that four different "second opinions"is a desirable thing? Do you believe that the collection and study of clinical inputs and outcomes, along with economic considerations can lead to a system with less variation in opinions?

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