Informatics:Informatics: The Foundation of Medical HomeThe Foundation of Medical Home

James L. Holly, MDJames L. Holly, MD

Family Medicine Leadership ConferenceFamily Medicine Leadership Conference

Dallas, TexasDallas, Texas

September 19, 2009September 19, 2009

““System thinking needed becauseSystem thinking needed becausehumankind has the capacity to:humankind has the capacity to:

Create more information than Create more information than anyone can absorbanyone can absorb

Foster greater interdependency Foster greater interdependency than anyone can managethan anyone can manage

Accelerate change faster than Accelerate change faster than anyone’s ability to keep pace.”anyone’s ability to keep pace.”

Too much informationToo much information

In 2004, the In 2004, the Journal of the Journal of the Medical Library AssociationMedical Library Association published an article entitled, published an article entitled, “How Much Effort is needed to “How Much Effort is needed to keep up with the literature keep up with the literature relevant to primary care?” Here relevant to primary care?” Here are the authors’ conclusions:are the authors’ conclusions:

Too much informationToo much information

There are 341 currently active journals There are 341 currently active journals which are relevant to primary care.which are relevant to primary care.

These journals publish approximately These journals publish approximately 7,287 articles monthly.7,287 articles monthly.

It would take physicians trained in It would take physicians trained in epidemiology an estimated 627.5 hours epidemiology an estimated 627.5 hours per month to read and evaluate these per month to read and evaluate these articles. That translates into 21 hours a articles. That translates into 21 hours a day, seven days a week, every month.day, seven days a week, every month.

In healthcare, the solution toIn healthcare, the solution tohelplessness is to “see” the:helplessness is to “see” the:

Interrelatedness of one disease Interrelatedness of one disease aggravating or precipitating aggravating or precipitating anotheranother

dynamic interaction between the dynamic interaction between the treatments of simultaneous treatments of simultaneous pathological processes.pathological processes.

Systems thinking and HealthSystems thinking and Health

Systems-thinking and the dataSystems-thinking and the data

display designed on thosedisplay designed on those

principles allow the provider toprinciples allow the provider to

““see” how the treatment of onesee” how the treatment of one

disease augments or complicatesdisease augments or complicates

the treatment of another.the treatment of another.

Creating Discomfort in ProviderCreating Discomfort in Provider

Creation of discomfort in theCreation of discomfort in the

provider via self-auditing at theprovider via self-auditing at the

point of care allowing the providerpoint of care allowing the provider

to measure his/her performanceto measure his/her performance

against an accepted standard.against an accepted standard.

““Treatment inertia”Treatment inertia”

““Lack of treatment intensification Lack of treatment intensification in a patient not at evidence-based in a patient not at evidence-based goals for care.”goals for care.”

““Dynamic Complexity”Dynamic Complexity”

This occurs when “cause and effect areThis occurs when “cause and effect are

subtle, and where the effects over time ofsubtle, and where the effects over time of

interventions are not obvious.”interventions are not obvious.”

““The real leverage in most managementThe real leverage in most management

situations lies in understanding “dynamicsituations lies in understanding “dynamic

complexity.”complexity.”

Data DisplayData Display

Data display can obscure effective Data display can obscure effective

management if it simply presentsmanagement if it simply presents

more detail while ignoring, ormore detail while ignoring, or

further obscuring, the dynamicfurther obscuring, the dynamic

interaction of one part of ainteraction of one part of a

biological system with another.biological system with another.

Seeing Circles of CausalitySeeing Circles of Causality

““Reality is made up of circles, but we seeReality is made up of circles, but we see

straight lines…Western languages…arestraight lines…Western languages…are

Biased toward a linear view. If we want toBiased toward a linear view. If we want to

see system-wide interrelationships, we needsee system-wide interrelationships, we need

a language of interrelationships, a languagea language of interrelationships, a language

of circles.”of circles.”

((The Fifth Disciple, Dr. Peter SengeThe Fifth Disciple, Dr. Peter Senge))

If excellent care requiresIf excellent care requireshealthcare organizations to:healthcare organizations to:

BBe “learning organizations”e “learning organizations” Avoid “learning disabilities”Avoid “learning disabilities” Think in a circular rather than a Think in a circular rather than a

linear fashionlinear fashion Look at dynamic complexity Look at dynamic complexity

rather than detail complexityrather than detail complexity

If health science has the capacity:If health science has the capacity:

To create far more information than To create far more information than anyone can absorb,anyone can absorb,

To foster far greater interdependency To foster far greater interdependency than anyone can managethan anyone can manage

To accelerate change far faster than To accelerate change far faster than anyone’s ability to keep pace.anyone’s ability to keep pace.

EMR PowerEMR Power

How can electronic patient records and/or How can electronic patient records and/or

electronic patient management help solveelectronic patient management help solve

these problems and make it possible forthese problems and make it possible for

healthcare providers to remain current andhealthcare providers to remain current and

fulfill their responsibility of caring forfulfill their responsibility of caring for

patients with the best treatments available?patients with the best treatments available?

Linear ThinkingLinear Thinking

Circular CausalityCircular Causality

Data flow to and from the patient’s coreData flow to and from the patient’s coreinformation, and to and from interactiveinformation, and to and from interactivedisease management capabilities:disease management capabilities:

Acute condition dataAcute condition data

Longitudinal dataLongitudinal data

Standards of care which reflect a positive state of Standards of care which reflect a positive state of

healthhealth

Automatically-populated-treatment reflecting best Automatically-populated-treatment reflecting best

practices based on random controlled trialspractices based on random controlled trials

Auditing tools which reflect provider excellenceAuditing tools which reflect provider excellence

Automatically-populated-patient follow-up instructions Automatically-populated-patient follow-up instructions

Automatically-created-patient educationAutomatically-created-patient education