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Are Technology Barriers Affecting
Best Practices and Quality of Care?
              T (Teo) Forcht Dagi
       MD, MPH, DMedSc, FAANS, FACS, FCCM
              HLM Venture Partners
 Harvard Medical School & Queen’s University Belfast
Disclosures
               Partner, HLM Venture Partners, Boston
             Chief medical officer, Aventura, Inc., Denver


  No compensation has been offered or received
       in conjunction with this presentation




02/04/2012               ©T Forcht Dagi 2012, all rights reserved   2
Technology
          Device or Set of Functional Tools
• Tools to leverage, extend and improve upon human
  capacities
      –      Strength
      –      Accuracy
      –      Communication
      –      Vision and the other senses
      –      Memory
      –      Calculation
      –      Speed and reaction time
      –      Reaction sequences
      –      Hazardous or otherwise impossible conditions
      –      Endurance

02/04/2012                  ©T Forcht Dagi 2012, all rights reserved   3
Technology
                    More Broadly
• Tools to overcome boredom and routine and
  mimic human capacity
      – Automation, including process automation
      – Robotics
• Tools to improve precision
• Tools that combine capabilities and processes
  in complex ways and for purposes not
  otherwise possible

02/04/2012           ©T Forcht Dagi 2012, all rights reserved   4
Limitations of Technology
•   Non-derivative novelty, ingenuity and creativity
•   True invention
•   Discretion
•   Autonomous “leaps”
•   Insight
•   Emotion
•   Kindness and personalization
•   Humor
02/04/2012          ©T Forcht Dagi 2012, all rights reserved   5
Technology as Barrier
•   Instruction s sets inadequate for purpose
•   Required sequences limit utility and versatility
•   Complexity of access
•   Access time
•   Process or data corruption and loss
•   Back-up systems
•   Alternative work processes
•   Uncoordinated components

02/04/2012         ©T Forcht Dagi 2012, all rights reserved   6
Best Practices in Medicine
                     Traditional
• History, examination, diagnosis, prognosis,
  treatment, follow-up, discharge
• Record for purposes of documentation and
  contribution to knowledge, left to the discretion
  of physician
• Document for billing purposes
• Personal engagement (doctor-patient-family)
• Good medicine highly dependent on physician
• Trust

02/04/2012          ©T Forcht Dagi 2012, all rights reserved   7
Best Practices in Medicine
                      Current
• Diagnostic and therapeutic process not substantially different
• Assisted by decision support systems
• Record also for purposes of compliance and oversight, so
  formalized
• Document for reimbursement, but also process and outcome
• Difficult to satisfy requirements without EHR
• Personal engagement emphasized less than system engagement
• Good medicine redefined to include prevention, but also matters of
  interest for economic and population
• Individual relationships supplanted?
• Trust in “system” rather than judgment of physician?
• Who is ultimately accountable?



02/04/2012             ©T Forcht Dagi 2012, all rights reserved    8
New “Best Practice” Icons
•   Reduce variance
•   Reduce error
•   Decision support
•   Track physician behavior
•   Engage and track patient behavior




02/04/2012          ©T Forcht Dagi 2012, all rights reserved   9
Obvious System Advantages and
          Support of Quality Measures
• Masses of data and data analytics, including predictive
  modeling
• System-wide resource allocation
• Contributors to disease and illness
• Confluence of the set and the statistic
• Genomic and epigenetic factors
• Enriched populations and other improvements in clinical
  trials
• Meaningful observational studies
• Trend tracking
• Synoptic medical records and patient portal
• Consumer engagement

02/04/2012          ©T Forcht Dagi 2012, all rights reserved   10
Efforts Needed to Retain Humanity
• Medicine should still be about patients
• Technology of tremendous value but
      – Easy to look at screen instead of patient
      – Easy to become caught up in protocolized work
        flow instead of remaining responsive to patient
      – Easy to define good medicine in terms of
        population outcomes rather than individual
        outcomes
      – Easy to anonymize care
02/04/2012            ©T Forcht Dagi 2012, all rights reserved   11
Technology Design
• The problem of technological positivism
• The problem of work flow persistence
• Can ignore or alienate clinicians
• Elegant technology solutions sometimes fail in
  the context of real world complexity
• The medical world is slow to change
• Legacy systems will be around for some time
• Physicians seek technological invisibility

02/04/2012      ©T Forcht Dagi 2012, all rights reserved   12
The Technology Challenge I
1.  Time required to enter, access and sign out of system
2.  Ergonomics of data entry, information access, retrieval, and
    management
3. How are data and system corrections managed?
4. How are upgrades and changes managed?
5. How invasive are decision support systems? Are they time-efficient,
    current, helpful and flexible?
6. Does the system provide for data support systems (genomics) as well as
    decision support systems (diagnosis, CPOE)?
7. Is it possible to get a “blink” of data?
8. Is it possible to access or print out the specific information needed (as
    opposed to the entire record)
9. Where are access points and are they sufficient?
10. Is all information available in appropriate (diagnostic, pictorial, graphic)
    form?


02/04/2012                  ©T Forcht Dagi 2012, all rights reserved               13
The Technology Challenge II
11. Is all information required accessible at the same station?
12. How to deal with interoperability of hospital facing units (pre-
    hospital, ER, ICU, OR, ward, case management) both within and
    across institutions (merged, affiliated or independent
13. How to deal with interoperability of outpatient systems?
14. Are all legacy systems compatible?
15. When and where should information be available in print form?
16. Are security routines automated?
17. How and when to override protocols?
18. Can the system contend with all therapeutic, administrative and
    teaching functions required and undertaken in the institution?
19. Is the system context sensitive to clinicians and patients?
20. How to practice when the system goes down?


02/04/2012              ©T Forcht Dagi 2012, all rights reserved       14
Is Technology a Barrier to Best
             Practices and Quality of Care?
• Double edged sword
• Technology can help optimize care
• Technology can be a barrier to care
• Technology is a tool to be deployed artfully
  and intelligently
• Technology should be developed in the service
  of work flow


02/04/2012            ©T Forcht Dagi 2012, all rights reserved   15
Summary
• Technology can both enable and impair best medical
  practices
• Good design must take into account the use context
• Useful technologies follow and do not attempt to
  change clinician work flows
• Because not all clinicians have the same work flow
  pattern, one size does not fit all
• Quality of care must remain patient centered rather
  than system centered
• Technological positivism does not work

02/04/2012         ©T Forcht Dagi 2012, all rights reserved   16

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Case Study “Are Technology Barriers Affecting Best Practices and Quality of Care?”

  • 1. Are Technology Barriers Affecting Best Practices and Quality of Care? T (Teo) Forcht Dagi MD, MPH, DMedSc, FAANS, FACS, FCCM HLM Venture Partners Harvard Medical School & Queen’s University Belfast
  • 2. Disclosures Partner, HLM Venture Partners, Boston Chief medical officer, Aventura, Inc., Denver No compensation has been offered or received in conjunction with this presentation 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 2
  • 3. Technology Device or Set of Functional Tools • Tools to leverage, extend and improve upon human capacities – Strength – Accuracy – Communication – Vision and the other senses – Memory – Calculation – Speed and reaction time – Reaction sequences – Hazardous or otherwise impossible conditions – Endurance 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 3
  • 4. Technology More Broadly • Tools to overcome boredom and routine and mimic human capacity – Automation, including process automation – Robotics • Tools to improve precision • Tools that combine capabilities and processes in complex ways and for purposes not otherwise possible 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 4
  • 5. Limitations of Technology • Non-derivative novelty, ingenuity and creativity • True invention • Discretion • Autonomous “leaps” • Insight • Emotion • Kindness and personalization • Humor 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 5
  • 6. Technology as Barrier • Instruction s sets inadequate for purpose • Required sequences limit utility and versatility • Complexity of access • Access time • Process or data corruption and loss • Back-up systems • Alternative work processes • Uncoordinated components 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 6
  • 7. Best Practices in Medicine Traditional • History, examination, diagnosis, prognosis, treatment, follow-up, discharge • Record for purposes of documentation and contribution to knowledge, left to the discretion of physician • Document for billing purposes • Personal engagement (doctor-patient-family) • Good medicine highly dependent on physician • Trust 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 7
  • 8. Best Practices in Medicine Current • Diagnostic and therapeutic process not substantially different • Assisted by decision support systems • Record also for purposes of compliance and oversight, so formalized • Document for reimbursement, but also process and outcome • Difficult to satisfy requirements without EHR • Personal engagement emphasized less than system engagement • Good medicine redefined to include prevention, but also matters of interest for economic and population • Individual relationships supplanted? • Trust in “system” rather than judgment of physician? • Who is ultimately accountable? 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 8
  • 9. New “Best Practice” Icons • Reduce variance • Reduce error • Decision support • Track physician behavior • Engage and track patient behavior 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 9
  • 10. Obvious System Advantages and Support of Quality Measures • Masses of data and data analytics, including predictive modeling • System-wide resource allocation • Contributors to disease and illness • Confluence of the set and the statistic • Genomic and epigenetic factors • Enriched populations and other improvements in clinical trials • Meaningful observational studies • Trend tracking • Synoptic medical records and patient portal • Consumer engagement 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 10
  • 11. Efforts Needed to Retain Humanity • Medicine should still be about patients • Technology of tremendous value but – Easy to look at screen instead of patient – Easy to become caught up in protocolized work flow instead of remaining responsive to patient – Easy to define good medicine in terms of population outcomes rather than individual outcomes – Easy to anonymize care 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 11
  • 12. Technology Design • The problem of technological positivism • The problem of work flow persistence • Can ignore or alienate clinicians • Elegant technology solutions sometimes fail in the context of real world complexity • The medical world is slow to change • Legacy systems will be around for some time • Physicians seek technological invisibility 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 12
  • 13. The Technology Challenge I 1. Time required to enter, access and sign out of system 2. Ergonomics of data entry, information access, retrieval, and management 3. How are data and system corrections managed? 4. How are upgrades and changes managed? 5. How invasive are decision support systems? Are they time-efficient, current, helpful and flexible? 6. Does the system provide for data support systems (genomics) as well as decision support systems (diagnosis, CPOE)? 7. Is it possible to get a “blink” of data? 8. Is it possible to access or print out the specific information needed (as opposed to the entire record) 9. Where are access points and are they sufficient? 10. Is all information available in appropriate (diagnostic, pictorial, graphic) form? 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 13
  • 14. The Technology Challenge II 11. Is all information required accessible at the same station? 12. How to deal with interoperability of hospital facing units (pre- hospital, ER, ICU, OR, ward, case management) both within and across institutions (merged, affiliated or independent 13. How to deal with interoperability of outpatient systems? 14. Are all legacy systems compatible? 15. When and where should information be available in print form? 16. Are security routines automated? 17. How and when to override protocols? 18. Can the system contend with all therapeutic, administrative and teaching functions required and undertaken in the institution? 19. Is the system context sensitive to clinicians and patients? 20. How to practice when the system goes down? 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 14
  • 15. Is Technology a Barrier to Best Practices and Quality of Care? • Double edged sword • Technology can help optimize care • Technology can be a barrier to care • Technology is a tool to be deployed artfully and intelligently • Technology should be developed in the service of work flow 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 15
  • 16. Summary • Technology can both enable and impair best medical practices • Good design must take into account the use context • Useful technologies follow and do not attempt to change clinician work flows • Because not all clinicians have the same work flow pattern, one size does not fit all • Quality of care must remain patient centered rather than system centered • Technological positivism does not work 02/04/2012 ©T Forcht Dagi 2012, all rights reserved 16