The healthcare community’s failure to use such clinical information systems has resulted in an ironic situation — despite drowning in oceans of information, there is serious a knowledge void:
  • An estimated half of all surgical operations and other medical procedures lack strict scientific evidence of their effectiveness and safety [1] and common procedures are prescribed that are not proven effective — up to 85 percent lack adequate scientific validation.[2] In other words, healthcare providers often don’t know what treatments work best for a particular patient.
  • Stakeholders do not have enough information about the quality of care — outcomes data about what works and what doesn’t — to enable them to make appropriate decisions.[3,4,4a] They are concerned that their decisions are based on limited or poor quality information. The consequences are enormous for everyone;
    • For private and public purchasers deciding which health plans will provide their employees with the best value for their premium dollar.
    • For providers striving to make sure patients have full information regarding treatment alternatives.
    • For health plans needing to manage enrollee health, monitor contracts with providers and facilities, and make financial decisions.
    • For consumers faced with selecting health plans, doctors, and other health professionals.
    • For public health officials responsible for maintaining community health.[5]
      In other words, those who pay for and receive healthcare don’t have the knowledge they need to make informed decisions.
  • Even when good information is available to support healthcare decisions, it often isn’t being used to improve care quality because the unaided human mind, no matter how competent, simply cannot focus on all the necessary details nor possess all the knowledge needed for continually making the best clinical decisions. Specialization and traditional information technology do not solve this problem. Consider the following;
    • The volume of clinical information expands exponentially[6] with more than 150,000 medical articles published each month in more than 20,000 biomedical journals.[7] Healthcare providers struggle to stay current with the clinical information, but inevitably become overloaded. This may contribute to the slow adoption of evidence-based research in clinical practice.[8,9] There is just too much clinical information being generated for providers to incorporate into their internal base of knowledge.
    • As a group, healthcare providers care about patients and take pride in doing an excellent job in caring for their well-being. Nevertheless, the “…task of knowing every detail is way beyond the [ability of] human mind… For example…diabetes care ought to take into account any of 120 management options and 380 possible patient conditions associated with the disease. …the unaided mind cannot reliably recall all the causes or management options that should be considered for each patient, nor can it recall all the findings in the patient needed to discriminate among those options, nor can it reliably match findings to options under the time constraints of practice.”[10]
    • In addition, “…most physicians are able to take into account only a portion of the diagnostic and management options potentially relevant to their patients and only a fraction of the evidence needed for choosing among those options. …Physicians do little better with the usual aids to medical decision making, such as practice guidelines and use of Internet resources. Those aids provide general knowledge, but do not ensure that the physician will recall all the data or successfully link it with a particular patient's specific problem.”[11]problems that cross specialty boundaries and require multiple specialists, yet the current healthcare system does a poor job at supporting communication between providers and assuring continuity of care. And primary care physicians are not equipped with the information tools necessary to grapple with the information overload, nor do they have a system for coordinated care within which to function.[12]
    • “Because physician time is expensive and scarce, their initial workups can be meager [as they] …act according to their own preconceived notions about what history, physical, and laboratory findings are worth checking. Equally idiosyncratic are the conclusions they draw from whatever data they select. Both selection and analysis of data are influenced heavily by their medical education, prior clinical experience, specialty orientation, contradictory clinical guidelines, financial concerns, cultural background, personal biases, and day-to-day time constraints, all of which vary enormously among individual practitioners.”[13,14]
  • A growing body of research in mind-body medicine not only demonstrates an undeniable interplay between biomedical, psychological, and social factors, but points specifically to a causal link between mental/emotional problems and many physical illnesses.[15,16,17,18,19,20,21,22] This means that medical practitioners must somehow be certain a patient’s bodily symptoms are not significantly influenced by psychological problems, even though few have the knowledge to make such determinations.
  • Not only do psychological problems affect medical care, but medical problems and medication side effects can appear to be mental health problems.[23,24] This means that mental health practitioners — including those without medical training — must somehow be certain a patient’s symptoms are not due to physical problems, even though few have the knowledge to make such determinations.
  • Knowledge about prescription medication safety and effectiveness is sometimes lacking. The Center for Drug Evaluation and Research is described as being “broken.” In a rush to approve drugs, a powerless FDA has been unable to assure that drugs it approves are safe and effective despite clinical trials. “… tens of millions of people may unknowingly have been exposed to the rare but serious side effects of a dozen common prescription drug-types…sold in 140 brand-names or generic version…[and] there are plenty of other [drugs] with worse risks.” Inadequate pre- and post-market research and the failure of companies to publish drug studies finding serious risks are two reasons for this.[25] In other words, our knowledge about the prescription medications can be faulty, resulting in tragic consequences.
  • “Each year, billions of U.S. tax dollars are spent on research and hundreds of billions are spent on service delivery programs. However, relatively little is spent on, or known about, how best to ensure that the lessons learned from research inform and improve the quality of health and human services and the availability and utilization of evidence-based approaches.[26] In other words, our country doesn’t focus enough on making existing healthcare knowledge useful and applicable to clinical practice.
  • “[There are significant] barriers to the adoption of evidence-based interventions that previous efficacy or effectiveness research has shown to be effective…[We] need to involve both interdisciplinary cooperation and trans-disciplinary collaboration, utilizing theories, empirical findings, and methods from a variety of fields not traditionally associated with health research. Relevant fields include: information science, clinical decision-making, organizational and management theory, finance, individual and systems-level behavioral change, anthropology, learning theory, and marketing. Meaningful research will include collaboration with stakeholders from multiple public health and/or clinical practice settings as well as consumers of services and their families/social networks.[27] In other words, there has been resistance in the healthcare industry to use scientific knowledge to help decision makers improve their performance.
  • The healthcare does not take advantage of the technologies used in other industries to manage knowledge. Hospitals continue to lag other industries in their IT investments.[28] “When healthcare information management matches the sophistication of [NASA’s] Mission Control, medicine will be ready for more quantum leaps.”[29]
  • “Decision-makers have few resources for learning quickly which patients are likely to benefit from new options and which patients will experience marginal benefits or outright harm. Payers and consumers confront the same knowledge chasm and lack good information for coverage decisions, cost sharing, and treatment choices. … evidence is infrequently available in a form that can be acted upon at the time decisions must be made. From clinical encounters to policy decisions, there are few clear pathways between the evidence that is available through peer-reviewed literature reviews and the point of decision making. Clinicians searching for information all too often find that existing knowledge is not accessible in real time and may not necessarily map to the issue at hand. Also, although consumers are increasingly active in seeking information about health and specific conditions, most of this activity is peripheral to care delivery.[30]
  • Obtaining the knowledge to improve decision-making requires a commitment to ongoing clinical outcomes research and a focus on continuous quality improvement — things that the healthcare industry has largely avoided. “…most improvement initiatives in this field have consisted of nonessential projects [such as]: reduce wait time for call-ins, MRI scheduling, increase capacity in X-ray, report turnaround time, discharge delays, improve patient satisfaction at ER, improve medical capacity, increase surgical capacity, improve the revenue cycle, employee safety, patient waiting time, call center defects, health care billing defects, educe in-patient waiting time, defective patient records, internal billing and insurance, rescheduling, operating room utilization, doctor utilization and wait time.”[31] If studying clinical outcomes was given the same degree of attention as optimizing financial gains and resource utilization, we would have much better knowledge for supporting diagnosis and treatment decisions.

All this means that until we focus on making the dissemination and implementation of useful scientific knowledge a top priority, we will continue to have serious quality problems and escalating costs due to ignorance, mistakes, and inefficiencies.

Blog links:
» Conversation on Healthvoices
» Conversation on Health Care Renewal

In the next section, we critically examine models designed to solve the healthcare crisis.

Next: Three Potential Solutions




Footnotes and References
(Click number in brackets to return to the text)
[1] New York Times (9/21/97)
[2] New York Times (4/29/98)
[3] New York Times (9/21/97)
[4] Bender, M. W. and Van Kuiken, S. J. (December 2005) IT remedies for US health care: An interview with WellPoint's Leonard Schaeffer. Available at http://www.mckinseyquarterly.com/article_abstract.aspx?ar=1696&L2=12&L3=63
[4a] Williams, D. (Oct. 13, 2006). More, Better Information Key in Fixing Health Care. ABC News Opinion. Available at http://abcnews.go.com/WNT/print?id=2563791
[5] Rand Corporation (Oct. 1997), Contracting For Provider Quality: Then, Now And P4P. Available at http://www.gosfield.com/PDF/ch3PDF.pdf
[6] Chassin MR. (1998). Is health care ready for Six Sigma quality? Milbank Quarterly. 76(4):565-91, 510.
[7] Levin A. (2001) The Cochrane Collaboration. Annals of Internal Medicine.135 (4): 309-12.
[8] Kohn L, ed, Corrigan J, ed, Donaldson M, ed. (1999) To err is human: building a safer health system. Institute of Medicine. Washington, DC: National Academy Press
[9] Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st century. Washington DC ( United States): Institute of Medicine.
[10] Health-IT World (2004) Dr. Weed's Software Cure. Available at http://www.health-itworld.com/emag/070104/289.html
[11] Weed. L. (2004). Shedding Our Illusions: A better Way of Medicine. 2(1):45-52. Available at http://www.srmjournal.org/article/PIIS154625010400009X/fulltext
[12] Weed, L. and Weed, L. (1994). Reeginerring Medicine. Federation Bulletin. 81(3).
[13] Wessel D. Capital. (March 20, 2002) The Wall Street Journal.online.
[14] Weed. L. (2004). Shedding Our Illusions: A Better Way of Medicine. 2(1):45-52. Available at http://www.srmjournal.org/article/PIIS154625010400009X/fulltext
[15] See NCCAM’s Mind-Body Medicine: Available at http://nccam.nih.gov/health/backgrounds/mindbody.htm
[16] Borysenko, J. (1988). Minding the Body, Mending the Mind. New York: Bantam.
[17] Dienstfrey, H. (1991). Where the Mind Meets the Body. New York: Harper Collins
[18] Gordon, J. S. & Bresler, D. (Eds.). (1984). Mind, Body and Health: Toward an Integral Medicine. New York: Human Sciences Press.
[19] Gordon, J. S. (1990). Stress Management. New York: Chelsa House
[20] Ornstein, R., & Sobel, D. (1988). The Healing Brain. New York: Simon & Schuster.
[21] Ornstein, R., & Sobel, D. (1990). Healthy Pleasures. Reading, Mass: Addison-Wesley.
[22] Why stress at work raises odds of heart disease. Reuters (Jan 19, 2006). Available at http://go.reuters.com/newsArticle.jhtml?type=healthNews&storyID=10911172&src=rss/healthNews
[23] Reeves, R. and Henderson, R. (2004). Recognizing medical emergencies presenting as psychiatric problems. JAAPA. 17:Web Available at http://www.jaapa.com/issues/j20040601/articles/wmedpsych0604.html
[24] Wrong Diagnosis.com. Symptom: Psychological problems. Available at http://www.wrongdiagnosis.com/sym/psychological_problems.htm
[25] Reports (Jan. 2006). Prescriptions for Trouble. 34-39.
[26] U.S. Dept of Health and Human Services (2005). Grant Notice #PAR-06-071. Dissemination and Implementation Research in Health.
[2]7 U.S. Dept of Health and Human Services (2005). Grant Notice #PAR-06-071. Dissemination and Implementation Research in Health.
[28] HIMSS Analytics and HIMSS Annual Report of the U.S. Hospital IT Market (2005)
[29] Business Week. (3/27/95). Medicine’s New Weapon: Data — Information Systems Improve Treatments and Save Money.
[30] Clancy, C.M. & Cronin, K. (2005), Evidence-Based Decision Making: Global Evidence, Local Decisions. Health Affairs; 24 (1): 151-162. Available at http://content.healthaffairs.org/cgi/content/abstract/24/1/151
[31] Brun, G. (2005). The White Elephant in the Room. Quality Digest web site at http://www.qualitydigest.com/june05/articles/05_article.shtml

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