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  • 1. “Deep Support” in Patient Care Reengineering Healthcare to Support Patient-Centered Communication and Continuity of Care Bradford W. Hesse, PhD Chief, Health Communication & Informatics Research Wednesday, June 18, 14
  • 2. Wednesday, June 18, 14
  • 3. A Lonely Road* Limited Support Cloistered knowledge Struggle with adherence Silo’ed & inaccessible records Fragmented care Doctor centric medicine * Hoffman, Jan. (2005,August 14, 2005).Awash in Information, Patients Face a Lonely, Uncertain Road, NewYork Times. Wednesday, June 18, 14
  • 4. “Greatest innovators (e.g., Henry Ford) ... discovered the possibility of a new kind of convergence between consumers’ desires, technological capabilities, and organizational innovations.” The Support Economy SOURCE: Zuboff, Shoshana, & Maxmin, James. (2002). The support economy : why corporations are failing individuals and the next episode of capitalism. New York: Viking. Wednesday, June 18, 14
  • 5. “Deep support provides ongoing relationship based on advocacy, mutual respect, trust, and the acute alignment of interests.” The Support Economy SOURCE: Zuboff, Shoshana, & Maxmin, James. (2002). The support economy : why corporations are failing individuals and the next episode of capitalism. New York: Viking. “The new digital technologies are essential to the successful consolidation of this new ... logic.” Example Wednesday, June 18, 14
  • 6. SOURCE: Hesse, B. W., & Shneiderman, B. (2007). eHealth research from the user's perspective. Am J Prev Med, 32(5 Suppl), S97-103. The Support Economy Wednesday, June 18, 14
  • 7. Why important? Wednesday, June 18, 14
  • 8. Wednesday, June 18, 14
  • 9. Just a 1% reduction would save $400 billion Wednesday, June 18, 14
  • 10. Source: Leyden WA, Manos MM, Geiger AM, Weinmann S, Mouchawar J, Bischoff K,Yood JG, Taplin SH (2005). Cervical cancer in women with comprehensive health care access: Attributable factors in the screening process. JNCI, 97(9), 675-683. FAILURE IN SUPPORT The Case of Cervical Cancer Wednesday, June 18, 14
  • 11. Systemic Errors in Medicine Wednesday, June 18, 14
  • 12. Accoun&ng  for  Two  Types  of  Error Errors of Commission: Doing something wrong (root cause of detectable errors) Errors of Omission: Failing to do something right (e.g., Pap failure - leads to more insidious consequences) Wednesday, June 18, 14
  • 13. Communica&on  Errors  at  Root Source: Mazor KM, Roblin DW, Greene SM, et al. Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. J Clin Oncol. May 20 2012;30(15):1784-1790. • Interviews with 416 cancer patients across 3 clinical sites (Mazor, et al, 2012) • Asked about events where something “went wrong,” the event could have been prevented, and the event could have caused significant harm. Results* • 28% described problem with medical care • 47% described a communication problem • 24% described problem with both communication and medical care * Of those reporting error Wednesday, June 18, 14
  • 14. 2008 Wednesday, June 18, 14
  • 15. Friedberg MW, Coltin KL, Safran DG, Dresser M, Zaslavsky AM, Schneider EC.Associations between structural capabilities of primary care practices and performance on selected quality measures.Ann Intern Med 2009;151(7):456-63. EHRS as Structural Capability Wednesday, June 18, 14
  • 16. HITECH Act Wednesday, June 18, 14
  • 17. Source: Hesse BW. Public Health Informatics. In: Gibbons MC, editor. eHealth Solutions for Healthcare Disparities. New York, NY: Springer; 2007. p. 109-129. Engaging Patients, Managing Populations Wednesday, June 18, 14
  • 18. Meaningful Use as Building Blocks Wednesday, June 18, 14
  • 19. Where are we? Wednesday, June 18, 14
  • 20. Surveillance July 27, 2012 See also: Hesse BW, Nelson DE, Rutten LF, Moser RP, Beckjord EB, Chou W-YS. National Health Communication Surveillance Systems. In: D. K. Kim ASGLK, ed. Global Health Communication Strategies in the 21st Century: Design, Implementation, and Evaluation. New York, NY: Peter Lang; In Press. . Health  Situa+onal   Awareness Wednesday, June 18, 14
  • 21. *NIH Nominee to White House for “Open Science Champion,” May 14 2013. Data Briefs Statistical Guides Peer Reviewed Publications Web Platform for Participation* Health  Informa+on  Na+onal   Trends  Survey  (HINTS) Surveillance Wednesday, June 18, 14
  • 22. HINTS  Brief  #1:  Trust  in  channels   and  cancer  informa+on  seeking Source: Hesse BW, Nelson DE, Kreps GL, et al.Trust and sources of health information: the impact of the Internet and its implications for health care providers: findings from the first Health Information NationalTrends Survey.Arch Intern Med. Dec 12-26 2005;165(22):2618-2624. Surveillance Wednesday, June 18, 14
  • 23. Where  would  you  prefer  to  go   for  cancer  informa+on? Source: Hesse BW, Nelson DE, Kreps GL, et al.Trust and sources of health information: the impact of the Internet and its implications for health care providers: findings from the first Health Information NationalTrends Survey.Arch Intern Med. Dec 12-26 2005;165(22):2618-2624. Surveillance Wednesday, June 18, 14
  • 24. Where  did  you  go  for  cancer   informa+on? Source: Hesse BW, Nelson DE, Kreps GL, et al.Trust and sources of health information: the impact of the Internet and its implications for health care providers: findings from the first Health Information NationalTrends Survey.Arch Intern Med. Dec 12-26 2005;165(22):2618-2624. Surveillance Wednesday, June 18, 14
  • 25. How  do  Survivors  get   their  cancer  informa+on? Source: Hesse BW,Arora NK, Beckjord EB, Finney Rutten LJ. Information Support for Cancer Survivors. Cancer. 2008;112(11S):2529-2540. Cancer Survivors Patient to Survivor: Lost in Transition? Surveillance Wednesday, June 18, 14
  • 26. Source: Hesse BW, Moser RP, Rutten LJ. Surveys of physicians and electronic health information. N Engl J Med. Mar 4 2010;362(9):859-860. Trends:  2002-­‐2003,  2005,  2008Surveillance Wednesday, June 18, 14
  • 27. HITECH*  Act  passed  in  2009 *Health  I.T.  for  Economic  &  Clinical  Health  Act Health I.T. as Foundation for Evidence Implementation Source: Hesse BW, Ahern DK, Woods SS. Nudging best practice: the HITECH act and behavioral medicine Translational Behavioral Medicine. 2011;1(1):175-181. Surveillance Wednesday, June 18, 14
  • 28. Source: Jamoom E, Beatty P, Bercovitz A, Woodwell D, Palso K, Rechtsteiner E. Physician adoption of electronic health record systems: United States, 2011. NCHS data brief. Jul 2012(98):1-8. National Ambulatory Medical Care Survey Supply  SideSurveillance Wednesday, June 18, 14
  • 29. Health Information National Trends Survey Demand  SideSurveillance Wednesday, June 18, 14
  • 30. Building Deep Support Wednesday, June 18, 14
  • 31. Two antiquated cultures in modern times -- the mechanistic and humanistic world views -- are leading to a “hidden epidemic” of error and chaos. - Kim Vicente, The Human Factor Wednesday, June 18, 14
  • 32. Competing World Views Mechanistic World View • Actors: Engineers, biological scientists • Question: How can we create new technologies? • Focus: Physical Object Vicente KJ. The human factor : revolutionizing the way people live with technology. 1st ed. New York: Taylor and Francis Books; 2003. Humanistic World View • Actors: Social scientists, physicians • Question: How can we create new people? • Focus: Person Wednesday, June 18, 14
  • 33. RESULTS Competing World Views Mechanistic World View • Actors: Engineers, biological scientists • Question: How can we create new technologies? • Focus: Physical Object Vicente KJ. The human factor : revolutionizing the way people live with technology. 1st ed. New York: Taylor and Francis Books; 2003. Humanistic World View • Actors: Social scientists, physicians • Question: How can we create new people? • Focus: Person Wednesday, June 18, 14
  • 34. Mechanistic World View • Actors: Engineers, biological scientists • Question: How can we create new technologies? • Focus: Physical Object Humanistic World View • Actors: Social scientists, physicians • Question: How can we create new people? • Focus: Person Competing World Views Wednesday, June 18, 14
  • 35. Institute of Medicine’s “Crossing the Quality Chasm” report Wednesday, June 18, 14
  • 36. Restructuring the decisional architectures of medicine* Hospital Based EHR Data Hospital Based EHR Data Health Information Exchange Medical Team Patient & Family Hospital System Decision Support Needs Subjective • Chief complaint • Patient Reported Outcomes • Risk modeling • Diagnostic support • Treatment selection • Guideline adherence • Error detection/correction Medical Researcher • Situational awareness • Population health • Continuity of care • Identify side effects • Inform discovery Objective • Clinical measures • Laboratory findings • Sensor data Assessment • Diagnosis • Categorical reporting • Prognosis Plan • Treatment planning • Self-care planning • Post treatment • Surveillance Source: Hesse BW. Decision Architectures. In D Bowen, M. Diefenbach, S. Miller (Eds.) Handbook of Health Decision Making. SpringerVerlag, NewYork, NY (in press). Meaningful Use Safety, efficiency Consumer engagement Continuity of care Population health Privacy Wednesday, June 18, 14
  • 37. Source: Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood). Mar 2011;30(3):464-471. Preponderance of evidence is showing a positive influence on care Wednesday, June 18, 14
  • 38. Bringing patients into the quality control process • 92% of patients opened notes • 60% reported better medication compliance • 77% reported being in greater control of care • 86% agreed that open notes would be factor in choosing care • 99% wanted open notes to continue Wednesday, June 18, 14
  • 39. Patient engagement in quality control endorsed by physicians Wednesday, June 18, 14
  • 40. How often is medicine “evidence- based”? • Medicine gets it right 54.9% of the time* • Pernicious incentives divert from evidence-based treatment** • Explosion of information makes it impossible to stay abreast of field • Historical premium on opinion-based care * McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348(26):2635-45 (June 26). ** Brawley OW, Goldberg P. How we do harm : a doctor breaks ranks about being sick in America. 1st ed. New York: St. Martin's Press; 2012. Wednesday, June 18, 14
  • 41. Create a self-improving healthcare system, with patients as partners Oncology as information science: “The Learning Health Care System” Wednesday, June 18, 14
  • 42. I.T. accounts for productivity growth in most sectors, but not Health Friends of the NLM Meeting 2009 Wednesday, June 18, 14
  • 43. But initial deployment is disrupting workflow Wednesday, June 18, 14
  • 44. National Research Council 2009 Report ComputationalTechnology for Effective Health Care advocates re-balancing the portfolio of investments in health care IT • Greater cognitive support for physicians, patients, and caregivers • Observing user-centered design principles • Accelerating research related to health care in the computer and social sciences and in health/biomedical informatics Wednesday, June 18, 14
  • 45. EricTopol, a cardiologist who directs the Scripps Translational Science Institute in San Diego, says apps that monitor blood pressure or glucose rates can be more valuable than prescriptions to keep these conditions in check. "When we use a medication, we don't know if it's going to work or not. It's much better when a person's taking their blood pressure on a frequent basis," saysTopol. "The average person looks at their smartphone 150 times a day, so all of a sudden they're able to diagnose if their blood pressure's adequately controlled and what are the circumstances when it's not." Patients lead the way Wednesday, June 18, 14
  • 46. But, with resistance ... The Case of Hugo Wednesday, June 18, 14
  • 47. But, with resistance ... The Case of Hugo Wednesday, June 18, 14
  • 48. But, with resistance ... The Case of Hugo Wednesday, June 18, 14
  • 49. Stimulating the market for consumer- facing apps Wednesday, June 18, 14
  • 50. Wednesday, June 18, 14
  • 51. How do we communicate at “point of need,” not just “point of care?” Wednesday, June 18, 14
  • 52. Moving toward a patient-centric model Source: Zuboff S, Maxmin J.The support economy: why corporations are failing individuals and the next episode of capitalism. NewYork:Viking; 2002. Technologies  focusing  on  the  long  term  rela&onship   with  a  customer  contribute  to  business  success* Move away from a “transactional” model to a “relationship” model Wednesday, June 18, 14
  • 53. Use new infrastructure to ensure equitable treatment across populations Meaningful Use Phase 3 will emphasize population health Wednesday, June 18, 14
  • 54. Erasing the barriers between clinical and public health Wednesday, June 18, 14
  • 55. Final Thoughts Wednesday, June 18, 14
  • 56. Rebuilding healthcare is like building a plane in flight ... Wednesday, June 18, 14
  • 57. Meaningful Use Can Guide Redesign Source: Hesse, Bradford W. (in press). Decisional Architectures. In M. A. Dieffenbach, S. M. Miller & D. Bowen (Eds.), Handbook of Health Decision Science. New York, NY: Springer Verlag. Wednesday, June 18, 14
  • 58. Target: Empowered Partners Wednesday, June 18, 14
  • 59. Wednesday, June 18, 14
  • 60. Deep Support Wednesday, June 18, 14
  • 61. Thank you! Slideshare.nethttp://www.slideshare.net/BradfordHesse Wednesday, June 18, 14