Using informatics to help physicians and patients make better decisions
As a physician and the founder of DynaMed, Brian Alper, class of 1996, knows that the right data set, used in the right way at the right time, can hold the answers to most of health care's problems.
"When was the last time you used a paper map to take you from Point A to Point B?" Alper asks. "Today I expect my iPhone to tell me how to walk three blocks and see what restaurants are available in whatever city I happen to be in. Navigating health care is more complex than navigating city streets, but as we apply functional solutions and current technology to support such navigation, the power of medical informatics becomes the power to share information in real time."
Alper's passion for computers began when he taught himself basic programming in elementary school and he quickly found that data was a valuable asset. "My father was a roofer and a truck driver. Despite limited resources, he bought and sold some low-cost real estate properties and set up personal loans to help people who could not get traditional mortgages. When I was in sixth grade, I used programming to create an amortization schedule for him so he could track his mortgages."
Later, he applied to medical school with the idea that he would practice in a rural area and help those who had limited access to care. While he was at Hahnemann, in the pre-internet era, he wanted to maximize his time getting hands-on experience in patient care settings and spend less time memorizing facts. He saw that he needed a systematic way to organize and consume the information he was getting in his classes.
Again, he turned to his computer and unknowingly began developing the foundation for a medical informatics hub. "I started creating what was essentially a database of my learning. At the time, I had a WordPerfect file for each topic — how to diagnose and treat each disease or condition. Since each file name could only have eight characters or letters, I made a table of contents that went on for 60 pages. Ultimately, these notes were more useful to me than textbooks because they were focused on patient care and because they were something I could bring with me wherever I went and easily reference."
During his fourth-year rotation in rural Tennessee, Alper used his notes often. He found that they made a big difference for patients, some of whom had been diagnosed incorrectly, and they made a difference for the doctors in practice every day. Alper set up the notes on their computer so they could be used after he left. "I realized that in 1995 in rural America, real doctors needed to have access to this information. I was going to figure out a way to make it available."
By December of that year, Dynamic Medical Information System, or DynaMed for short, was born. "My mission then, and for more than 20 years, was to provide the most useful information for health care professionals at the point of care," he says.
INFORMATION MEETS INTEREST
Alper spent the next several years — as he simultaneously worked through his family medicine residency and a faculty development/research fellowship — creating a network of physicians to help generate and review content. He worked with programmers to build a database so that the information could be easily shared, updated and accessed. Word spread quickly and the product grew at a powerful clip as Alper's concept dovetailed with a growing interest in evidence-based medicine.
"At that point, I had never heard the term evidence-based medicine, but I found that many physicians were looking for this information and wanted support in their clinical decision making," he says. "For most of them, the reality was that they spent all day with patients, and there was no time for the constant learning required to stay on top of the latest research."
In 2005, EBSCO Health acquired DynaMed, and Alper's product was rebuilt with more content, mobile capabilities and new features. It was relaunched in 2014 as DynaMed Plus. Today, DynaMed Plus covers more than 5,000 topics, with hundreds of contributors providing and reviewing information and thousands of physicians using it daily, linking directly from patients' electronic medical records. Millions have access to it through subscriptions at their hospitals, health care systems or professional societies.
The basic concept that Alper developed remains the same — a service that provides the best answer to real-time questions physicians must answer during patient encounters. The biggest change is that recommendations are now labeled as "strong" if they are supported by a high degree of confidence and independent verification, and "weak" if they are not. "It's no longer enough to just have the facts. Doctors today are also looking for value judgments but still need to know the trustworthiness of those value judgments," Alper says.
A PATIENT APPROACH
Informatics also now helps answer questions that could not be handled well by summarizing facts and recommendations alone, such as patient care scenarios requiring individual attention. One example is the problem of atrial fibrillation, a common cardiac condition for which there are at least 11 different treatments that help prevent a stroke. Yet each patient, depending on their risk of stroke or bleeding, medical history and medications, will require a different approach.
Physicians have come to rely on informatics in the consultation room as they've moved from what Alper calls "just in case" learning to "just in time" learning. Now, Alper says, physicians are looking for "just for me" learning that takes into account patient diagnoses, medications, lab values, insurance plans and personal desires.
Indeed, a generation of health care providers only knows the practice of medicine with these aids. "It's become critically important to have evidence-based information in the order set. We have all this data now that we can be using, not only to support decision making but to educate heath care professionals in real time, which would be impossible to do otherwise," says Baber Ghauri, MD, MBA, class of 2004, chief medical information officer of St. Mary Medical Center and the East Division of Trinity Health system (see "Following the Data to Better Care").
Alper is currently working on a new project: patient decision aids that promote greater participation in shared decision making. "We have started seeing the mission as applying not just to doctors but to patients themselves," he says. "The new system we're developing is designed to address the questions patients will have. Doctors can pull decision aids from the system that offer option grids to compare a manageable number of treatment possibilities and help patients conduct their own risk-benefit analysis through the filter of their individual values. The conversation could be put into the medical record and the patient portal, and it could show the cost for the treatment in a generic way."
He's also been using informatics to help shape health guidelines, which can differ across organizations, professional bodies and nations. In 2011, he worked with the Costa Rican government to create comprehensive national guidelines for the treatment of breast cancer, adapting the recommendations from DynaMed's vast body of data. He's now working with international leaders to map out better ways to develop guidelines and convey that information to physicians and patients.
Informatics also has great potential in population health management, with the data scaled in any direction to help a larger swath of patients.
THE BIGGER PICTURE
Informatics also has great potential in population health management, with the data scaled in any direction, across multiple platforms to help a larger swath of patients, Alper says. "If you have limited resources — and who doesn't? — you can use informatics or data analysis to identify the most common and important problems to address with your resources. You may discover a problem is common enough that you develop innovative mass solutions. You may discover ‘unpredicted health' and find a subgroup of the population with fewer problems than expected, and perhaps learn something that could be beneficial for others. I remember a drug warning that a diabetes medication common at the time caused liver failure. Before computer-based records, I had to wait until each of my patients with diabetes came back for a scheduled visit to recognize, first, which of my patients had diabetes and, then, which ones were taking the drug so I could warn them and switch medicines. Today, we can find those patients quickly across the population and let them know immediately."
Alper envisions informatics playing a role in fundamentally reshaping the way health care is delivered, particularly with regard to Medicare. "We still count the number of things we document while examining the patient to determine how much we get paid for providing health care services. The electronic medical record has largely grown to document this for payment. Imagine if your doctor was paying more attention to you and less to typing into the computer during a visit.
"The change I would like to see in Medicare is to make the payment rules no longer based on documenting so many observations but to shift toward measures of volume and complexity of decision making, perhaps simply documenting the number of decisions made with the patient. The result would be medical records that are more meaningful and greater engagement between physician and patient. If we can find the better interplay between informatics and how we pay for health care, we can get much better value in what we get out of health care. I have suggested such changes, and I'm hoping that this will ultimately be one of the most influential changes I can be part of."
Alper no longer sees patients, as DynaMed and his leadership role is more than a full-time job, he says. While he misses practicing medicine, the personal rewards of his work in informatics, given their potential to positively effect change on a much larger scale, have been great. "I like solving problems and making an impact. I may not get the many instant gratification reactions that I got when I was seeing patients, but I still get [positive feedback] indirectly when physicians using the tool tell me stories about how it makes a difference. I didn't know 20 years ago that the bigger picture was so much bigger."
FOLLOWING THE DATA TO BETTER CARE
As chief medical information officer of St. Mary Medical Center and the East Division of the Trinity Health system, Baber Ghauri, MD, class of 2004, deploys informatics for decision making across many aspects of management. "My role is to collect data and use it to create meaningful changes in the hospital and health system. Most recently, our hospital leadership has been engaged in conversations about improving communication, and making sure that doctors and nurses check in with each other about each patient, every day. We had discovered that nurses and doctors weren't always having these check-ins, which was an important part of the care process."
Data points provide a clear picture of problems and solutions, but they also serve as a universal language that doctors, nurses, administrators and staff respond to. "It's easy to talk about improving this or that practice, but when you can show people how they are actually performing in a graph or with statistics, that changes the conversation," he says.
In another recent example, Ghauri is helping to improve patient readmission rates by deploying HealthShare Exchange, the regional Health Information Exchange platform for hospitals. "If someone is discharged from St. Mary, and then goes to another emergency department a few days or weeks later, their care manager [at St. Mary] will get a notification. The care manager will call the emergency department doctor to share information they might not have at their fingertips. In most cases, the patient can be safely brought back to a private care doctor or specialist who can treat them, without having to be readmitted."
Ghauri sees that the scope of his work has evolved in tandem with the health care industry's use of informatics. "The CMIO role has really changed in recent years," Ghauri says. "At first, we were largely just implementation specialists for electronic medical records systems, but now we are more involved with analytics and using data to help drive patient outcomes."
Sometimes that requires questioning the work flow of a given process — often, how things have "always been done." "Recently, we were talking about colonoscopy screenings and how patients need to be referred to a GI specialist to get a colonoscopy. We questioned why we couldn't just send the patient to get a colonoscopy and eliminate the often unnecessary step of initial consultation with the gastroenterologist. Many times it's about leadership and challenging our processes, using the data as a starting point."
As both physician and administrator, Ghauri has witnessed firsthand how health care safety, efficiency and quality have evolved through advances in informatics. The adoption of electronic health records, guided by the objectives of Meaningful Use created by the U.S. HITECH Act, has ensured better treatment and lower costs — a process that is still evolving. "Without a doubt, Meaningful Use has helped us improve patient care," he says. "As we move toward Stage Three [advanced use of health technology] in the coming months and improving health outcomes, we are looking at better ways to leverage that data to benefit population health."
Ghauri, who still practices internal medicine, has also recently been certified in integrative medicine, and he finds its systemic approach useful both for improving patient health and for thinking about what conventional medicine could be doing better.
"Some people find it odd that I am interested in informatics and also talking about non-conventional treatments. To me, it's not a contradiction. Integrative medicine is ‘root cause' medicine, and it has opened my eyes to a lot of issues in health care. Why, for example, do patients that have back pain get a prescription for a painkiller that only masks their symptoms when they could get a $100 inversion table and a few massage treatments that will address the root cause of the problem? We need to be using more of the information we have and making it more widely available so that physicians and patients can make better decisions."
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