For more information: http://www.lifebot.us.com/teletriage/

Roger Heath

“Deep disorder pervades medical practice. Disguised in euphemisms like “clinical judgment” and “evidence-based medicine,” disorder exists because medical practice lacks a true system of care. The missing system has two core elements: standards of care for managing clinical information, and electronic information tools designed to implement those standards. Electronic information tools are now widely discussed, but the necessary standards of care are still widely ignored.

Because these two elements are external to the physician’s mind, they address a root cause of disorder: dependence on the internal capacities of autonomous physicians-their personal knowledge, intellect, habits and judgment. In this dependence on the limited, idiosyncratic capacities of individuals, medical practice lags centuries behind the domains of science and commerce. Breaking that dependence is the subject of this book.

Going back 400 years to the philosophy of Francis Bacon, and examining parallel ideas from 20th Century thinkers, this book illuminates the origin of medicine’s disorder. The analysis is more than theoretical. It grew out of decades of development and clinical experience in finding a new approach to medical practice. Designed to create order and transparency, this new approach involves not only standards and tools but also institutional changes essential to building a true system of care.

In the current non-system, physicians bear impossible burdens of performance, other practitioners are barred from sharing those burdens, patients do not participate effectively in their own care, the U.S. spends $2.5 trillion annually without clinical accounting standards, third parties manipulate the situation for their own advantage, and none of the stakeholders are accountable for their own behaviors.

This book offers a clear blueprint for building a better system of care, a system that patients, practitioners and third parties could trust. A better system could make health care a source of hope for our economic future, rather than its greatest threat.”

Since 2005, the eHealth Initiative has reported on the development and sustainability of RHIOs and State Designated Entities (SDEs) across the United States. Kuperman cites the 2010 eHealth Initiative HIE Survey Key Findings (available at http://www.ehealthinitiative.org/members-download/finish/4-open/35-hie-survey-report-2010-key-findings.html ) to substantiate the existence of 73 “operational” initiatives, but he does not mention that among those, the report finds that only 18 can be described as “sustainable” – sustained on operational revenue alone and not dependent on federal funding. One of the findings states that “Sustainability is an attainable goal for health information exchange organizations. There is a small but critical mass of sustainable organizations. ” This finding is without adequate foundation in the eHealth Initiative data analysis or results published in other studies of health care organization. In Kuperman’s perspective, the terms HIE and RHIO refer to organizations that address the” business issues of interoperability”, but critical review of eHealth Initiative research (as well as other published scholarly articles) suggests that sustainable business models have not been identified.

My reviews of the eHealth Initiative HIE surveys reveal some methodological deficiencies that tend to invalidate published study conclusions. (See http://eresearchcollaboratory.blogspot.com/2009/10/health-information-exchange-update.html . The review published on my blog was completed before the eHealth Initiative restricted access to their annual HIE surveys.) From year to year, the eHealth Initiative reports that the number of HIE initiatives has increased – without adequately accounting for sample mortality or changes in their definition of RHIOs – now called HIE initiatives and including SDEs as well as RHIOs.
In another recent publication – part of a program of research based in part on HIE (including RHIOs and SDEs) census data from the eHealth Initiative – Adler-Milstein et al. (2011) elaborate the definition of a “comprehensive RHIO” in light of the HIE requirements for meaningful use of electronic health records (EHRs). This definition was developed by a panel of 9 national health policy experts using a Delphi methodology to arrive at consensus. Analysis revealed that none of the RHIOs included in the sample satisfied the definitional criteria. (See Julia Adler-Milstein, David W. Bates and Ashish K. Jha, 2011, A Survey of Health Information Exchange Organizations in the United States: Implications for Meaningful Use, Annals of Internal Medicine, 154(10) 666-671 available at http://www.annals.org/content/154/10/666.abstract )

This finding and others reported in related research portend the possible failure of the market driven “network of networks” approach to development of the NHIN. Such disappointing results may also be attributed to the short time frame (2-4 years) for public funding in support of RHIOs and SDEs as well as the requirement that they develop business models to generate revenue streams from private stakeholders and system users. (The 2011 edition of the eHealth Initiative HIE Survey observes an increase in the number of HIE initiatives relying on federal funding. See http://www.ehealthinitiative.org/images/stories/2011_HIE_Forum/2011_Report_on_HIE_Key_Findings.pdf )

Sustainable business models are all the more difficult to identify given that health care services are in a constant state of flux with new organizational arrangements such as ACOs transforming existing configurations. Further complicating the business case, significant benefits of health information exchange often accrue at the system level rather than the individual provider or payer level of analysis. Adler-Milstein et al. (2011) conclude that their findings “…call into question whether RHIOs in their current form can be self-sustaining and effective in helping U.S. physicians and hospitals engage in robust HIE to improve the quality and efficiency of care.” (See Conclusion: article abstract.) Questions raised in this study suggest that the “network of networks” strategy based on the sustainability of RHIOs (and SDEs) cannot be assumed – as in Kuperman’s analyses of projects, such as Direct and Connect for health information exchange in the context of health sector market dynamics.

The second issue related to infrastructures required for health information exchange is the creation of a unique patient identifier. As mentioned above, Kuperman suggests that such an identifier was shown to be unnecessary in early demonstration projects for the NHIN and the “network of networks” approach. Kuperman argues that the advantage of a PUSH model such as Direct is to avoid the necessity of linking patient identifiers across systems before data transfer between health care organizations. While directories of authorized organizations (and their identifiers) would have to be established – individual patients would be identified by the authorized senders and receivers using internal matching algorithms– or even manual procedures. This approach would probably be sustainable in small-scale systems, but entirely impracticable at the regional and national levels (not to mention the global level) as the volume of data increases with mobility and diversity of patient populations served. The fundamental need for a unique patient identifier remains unresolved.

According to Kuperman, clinicians will expect both PUSH and PULL service dynamics for health information exchange, including transmission among providers as well as retrieval of individual patient data across the entire health care system. The responsibility for designing and managing these services apparently resides with RHIOs under the assumption of their sustainability: “As RHIOs (grapple) struggle to support interoperability-based services that improve the quality and efficiency of care, they will have the opportunity to understand how best to combine pull- and push-oriented capabilities.” (page 681) Given the ongoing failure of federal investments in RHIOs, SDEs and the “network of networks” strategy to develop infrastructure, this policy proposition lacks credibility and remains unfounded in research evidence or policy experience.

The article’s content seems to be several years (well, maybe 2) behind the awareness of everyone else who’s been looking at it. Si? No?

Bing H Tang, MD, MPH

Research & Ethics

Danville, California, U S

I read with interest Facebook activity of residents and fellows and
its impact on the doctor–patient relationship (J Med Ethics
jme.2010.036293Published Online First: 15 December 2010
doi:10.1136/jme).

Basically, facebook is a way of making oneself known to another, and,
in so doing, asking the other person to make him/herself known to you.
The “primitive” yet VERY personal Facebook method, one known to me
since my boyhood in the Far East, is to offer my Calling card on
which basic data about myself are contained, to the person I have just
met. As I say my name, out of my pocket comes the little card on which
my “face” is revealed: name, address, title, and all degrees I earned,
telephone, telegram, and what not. The “primitive” is, as well, the
very personal way. It appears to be inconvenient as following: on
meeting a stranger, one does not have one’s calling card handy and
give it to the “stranger”.

Facebook, today has expanded globally. It’s the mechanized system of
exchanging your personality and whatever else you want to add to the
world. Once you are on Facebook, millions of people, potentially, can
find you. The big question for someone, would be, “How much do you
want to reveal.

Facebook, in fact, is YOU-dominated platform, therefore you decide
what privacy you want to keep, as well, what you want to reveal.

If one doest not use it as a device to find friends, as well, not for
playing games do not etc either, nor can I see any risk of using it.

If one uses the New high technique and also very cautious to keep
reminding oneself to refrain from what not to be used, it will be
little risk involved.

As to the question of whether or not Facebook is “ethical”, I think
“ethical” in this connection has little or nothing to do with
Facebook.

If doctors only want to discuss a case, all personal information of
this particular patient could be codified that nobody over the web can
identify the patient’s identity, and still achieve the objective of
discussing a case. Doctors should know the risk over the web, and try
to wear the patient’s shoes on going facebook talking about his
patient. Not do onto others that you don’t like people do onto you, or
even one more step further, do onto others that you wish people did
onto you, as Christ taught.

[1] Wilson S, Johnston J, More trouble with Facebook. Privacy Law
Bulletin 2010;7.2:25-8.

[2] Michael Zimmer blog, Facebook’s Zuckerberg: “Having two identities
for yourself is an example of a lack of integrity” 14 May 2010
http://michaelzimmer.org/2010/05/14/facebooks-zuckerberg-having-two-
identities-for-yourself-is-an-example-of-a-lack-of-integrity.

[3] Facebook activity of residents and fellows and its impact on the
doctor–patient relationship
Ghassan Moubarak, Aurélie Guiot, Ygal Benhamou, Alexandra Benhamou, Sarah Hariri
J Med Ethics jme.2010.036293Published Online First: 15 December 2010
doi:10.1136/jme.2010.036293

I am searching for the survey questionnaire for one paper (EHR Acceptance Factors in Ambulatory Care: A Survey of Physician Perceptions) and I can not find it.

It has been mentioned in the paper that “copies of the survey are available from the authors”.
Would you please help me and tell me how may I have access to it?

Regards,
Omid