hesse hopkins 2014

“Deep Support” in Patient CareReengineering Healthcare to Support Patient-Centered

Communication and Continuity of Care

Bradford W. Hesse, PhDChief, Health Communication & Informatics Research

Wednesday, June 18, 14

A Lonely Road*

Limited Support

Estranged from research enterprise

Subject to common errors of omission in

Cloistered knowledge

Struggle with adherence

Silo’ed & inaccessible

records

Fragmented care

Doctor centric medicine

* Hoffman, Jan. (2005, August 14, 2005). Awash in Information, Patients Face a Lonely, Uncertain Road, New York Times. Wednesday, June 18, 14

“Greatest innovators (e.g., Henry Ford) ... discovered the possibility

of a new kind of convergence between consumers’ desires, technological capabilities, and organizational innovations.”

The Support Economy

SOURCE: Zuboff, Shoshana, & Maxmin, James. (2002). The support economy : why corporations are failing individuals and the next episode of capitalism. New York: Viking.

“Deep support provides ongoing relationship based on advocacy, mutual respect, trust, and the acute

alignment of interests.”

The Support Economy

SOURCE: Zuboff, Shoshana, & Maxmin, James. (2002). The support economy : why corporations are failing individuals and the next episode of capitalism. New York: Viking.

“The new digital technologies are essential to the successful

consolidation of this new ... logic.”

Example

SOURCE: Hesse, B. W., & Shneiderman, B. (2007). eHealth research from the user's perspective. Am J Prev Med, 32(5 Suppl), S97-103.

The Support Economy

Why important?

Just a 1% reduction would save $400 billion

Source: Leyden WA, Manos MM, Geiger AM, Weinmann S, Mouchawar J, Bischoff K,Yood JG, Taplin SH (2005). Cervical cancer in women with comprehensive health care access: Attributable factors in the screening process. JNCI, 97(9), 675-683.

FAILURE IN SUPPORTThe Case of Cervical Cancer

Systemic Errors in Medicine

Accoun&ng for Two Types of Error

Errors of Commission: Doing something wrong (root cause of detectable errors)

Errors of Omission: Failing to do something right (e.g., Pap failure - leads to more insidious consequences)

Communica&on Errors at Root

Source: Mazor KM, Roblin DW, Greene SM, et al. Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. J Clin Oncol. May 20 2012;30(15):1784-1790.

• Interviews with 416 cancer patients across 3 clinical sites (Mazor, et al, 2012)

• Asked about events where something “went wrong,” the event could have been prevented, and the event could have caused significant harm.

Results*• 28% described problem with

medical care

• 47% described a communication problem

• 24% described problem with both communication and medical care

* Of those reporting error

Friedberg MW, Coltin KL, Safran DG, Dresser M, Zaslavsky AM, Schneider EC. Associations between structural capabilities of primary care practices and performance on selected quality measures. Ann Intern Med 2009;151(7):456-63.

EHRS as Structural Capability

HITECH Act

Source: Hesse BW. Public Health Informatics. In: Gibbons MC, editor. eHealth Solutions for Healthcare Disparities. New York, NY: Springer; 2007. p. 109-129.

Engaging Patients, Managing Populations

Meaningful Use as Building Blocks

Where are we?

Surveillance

July 27, 2012

See also: Hesse BW, Nelson DE, Rutten LF, Moser RP, Beckjord EB, Chou W-YS. National Health Communication Surveillance Systems. In: D. K. Kim ASGLK, ed. Global Health Communication Strategies in the 21st Century: Design, Implementation, and Evaluation. New York, NY: Peter Lang; In Press.

Health Situa+onal Awareness

*NIH Nominee to White House for “Open Science Champion,” May 14 2013.

Data BriefsStatisticalGuides

Peer Reviewed Publications

Web Platform for Participation*

Health Informa+on Na+onal Trends Survey (HINTS)

Surveillance

HINTS Brief #1: Trust in channels and cancer informa+on seeking

Source: Hesse BW, Nelson DE, Kreps GL, et al. Trust and sources of health information: the impact of the Internet and its implications for health care providers: findings from the first Health Information National Trends Survey. Arch Intern Med. Dec 12-26 2005;165(22):2618-2624.

Surveillance

Where would you prefer to go for cancer informa+on?

Surveillance

Where did you go for cancer informa+on?

Surveillance

How do Survivors get their cancer informa+on?

Source: Hesse BW, Arora NK, Beckjord EB, Finney Rutten LJ. Information Support for Cancer Survivors. Cancer. 2008;112(11S):2529-2540.

Cancer Survivors

Patient to Survivor: Lost in Transition?

Surveillance

Source: Hesse BW, Moser RP, Rutten LJ. Surveys of physicians and electronic health information. N Engl J Med. Mar 4 2010;362(9):859-860.

Trends: 2002-‐2003, 2005, 2008Surveillance

HITECH* Act passed in 2009*Health I.T. for Economic & Clinical Health Act

Health I.T. as Foundation for Evidence

Implementation

Source: Hesse BW, Ahern DK, Woods SS. Nudging best practice: the HITECH act and behavioral medicine Translational Behavioral Medicine. 2011;1(1):175-181.

Surveillance

Source: Jamoom E, Beatty P, Bercovitz A, Woodwell D, Palso K, Rechtsteiner E. Physician adoption of electronic health record systems: United States, 2011. NCHS data brief. Jul 2012(98):1-8.

National Ambulatory Medical Care SurveySupply SideSurveillance

Health Information National Trends SurveyDemand SideSurveillance

Building Deep Support

Two antiquated cultures inmodern times -- the mechanisticand humanistic world views -- areleading to a “hidden epidemic” oferror and chaos.

- Kim Vicente,The Human Factor

Competing World ViewsMechanistic World View• Actors: Engineers, biological scientists• Question: How can we create new

technologies?• Focus: Physical Object

Vicente KJ. The human factor : revolutionizing the way people live with technology. 1st ed. New York: Taylor and Francis Books; 2003.

Humanistic World View• Actors: Social scientists, physicians• Question: How can we create new

people?• Focus: Person

RESULTS

Competing World ViewsMechanistic World View• Actors: Engineers, biological scientists• Question: How can we create new

Vicente KJ. The human factor : revolutionizing the way people live with technology. 1st ed. New York: Taylor and Francis Books; 2003.

Mechanistic World View• Actors: Engineers, biological scientists• Question: How can we create new

Competing World Views

Institute of Medicine’s “Crossing the Quality Chasm” report

Restructuring the decisional architectures of medicine*

Hospital Based EHR Data

Health Information Exchange

MedicalTeam

Patient &

FamilyHospital System

DecisionSupportNeeds

Subjective• Chief complaint• Patient Reported Outcomes

• Risk modeling• Diagnostic support • Treatment selection • Guideline adherence• Error detection/correction

Medical Researcher

• Situational awareness• Population health• Continuity of care• Identify side effects• Inform discovery

Objective• Clinical measures• Laboratory findings • Sensor data

Assessment• Diagnosis• Categorical reporting• Prognosis

Plan• Treatment planning• Self-care planning• Post treatment• Surveillance

Source: Hesse BW. Decision Architectures. In D Bowen, M. Diefenbach, S. Miller (Eds.) Handbook of Health Decision Making. Springer Verlag, New York, NY (in press).

Meaningful Use

Safety, efficiency

Consumer engagement

Continuity of care

Population health

Privacy

Source: Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood). Mar 2011;30(3):464-471.

Preponderance of evidence is showing a positive influence on care

Bringing patients into the quality control process

• 92% of patients opened notes

• 60% reported better medication compliance

• 77% reported being in greater control of care

• 86% agreed that open notes would be factor in choosing care

• 99% wanted open notes to continue

Patient engagement in quality control endorsed by physicians

How often is medicine “evidence-based”?

• Medicine gets it right 54.9% of the time*

• Pernicious incentives divert from evidence-based treatment**

• Explosion of information makes it impossible to stay abreast of field

• Historical premium on opinion-based care

* McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348(26):2635-45 (June 26).** Brawley OW, Goldberg P. How we do harm : a doctor breaks ranks about being sick in America. 1st ed. New York: St. Martin's Press; 2012.

Create a self-improving healthcare system, with patients as partners

Oncology as information science: “The Learning Health Care System”

I.T. accounts for productivity growth in most sectors, but not Health

Friends of the NLM Meeting

But initial deployment is disrupting workflow

National Research Council 2009 Report

Computational Technology for Effective Health Care advocates re-balancing the portfolio of investments in health care IT

• Greater cognitive support for physicians, patients, and caregivers

• Observing user-centered design principles

• Accelerating research related to health care in the computer and social sciences and in health/biomedical informatics

Eric Topol, a cardiologist who directs the Scripps Translational Science Institute in San Diego, says apps that monitor blood pressure or glucose rates can be more valuable than prescriptions to keep these conditions in check.

"When we use a medication, we don't know if it's going to work or not. It's much better when a person's taking their blood pressure on a frequent basis," says Topol.

"The average person looks at their smartphone 150 times a day, so all of a sudden they're able to diagnose if their blood pressure's adequately controlled and what are the circumstances when it's not."

Patients lead the way

But, with resistance ...

The Case of Hugo

Stimulating the market for consumer-facing apps

How do we communicate at “point of need,” not just “point of

care?”

Moving toward a patient-centric model

Source: Zuboff S, Maxmin J. The support economy: why corporations are failing individuals and the next episode of capitalism. New York: Viking; 2002.

Technologies focusing on the long term rela&onship with a customer contribute to business success*

Move away from a “transactional”

model to a “relationship” model

Use new infrastructure to ensure equitable treatment across populations

Meaningful Use Phase 3 will emphasize

population health

Erasing the barriers between clinical and public health

Final Thoughts

Rebuilding healthcare is like building a plane in flight ...

Meaningful Use Can Guide Redesign

Source: Hesse, Bradford W. (in press). Decisional Architectures. In M. A. Dieffenbach, S. M. Miller & D. Bowen (Eds.), Handbook of Health Decision Science. New York, NY: Springer Verlag.

Target: Empowered Partners

Deep Support

Thank you!

Slideshare.nethttp://www.slideshare.net/BradfordHesse

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