Kayaks, Perspective, and Decision Support for Meaningful Use

I took these photos from a Kayak, while having a great time paddling around on the Potomac River.

Although the phenomena of the moving monuments is simply the parallax we all learned in high school, the relevance to Meaningful Use is actually very profound.

The clinical observations or data (photos in our analogy) we collect over time in our EHRs often conflict with other observations. Some are clearly collected at different times and may represent an important trend. At other times, many other times in fact, the observations of two care providers about the same patient at the same time don’t agree. One doctor’s assessment is incurable Stage 4 cancer. A second opinion by another doctor indicates it’s “not a death sentence;” it’s both Stage 3 and highly likely curable. Both doctors file their semantically interoperable consultations into the same EHR.

The inter-relationships of the clinical processes, user workflows and applications, as well as their independence, assures that we will be collecting a lot of conflicting observations, interpretations and recommendations.

I work with clients who are pursuing and meeting Meaningful Use criteria. Within their EHRs, conflicts show up in problem lists, generalized order sets for individual conditions, and in patient summaries. However, when a record is viewed by other providers, the patient or institutions, distinctly different insights and perspectives may be drawn. Since the majority of patients have more than one problem on their list, and often these can be thought of as co-morbidities, there’s a need to manage this implied complexity.

For example, if a patient presents with both palpitations and a stroke, or heart failure and lung disease, there’s a high likelihood that the order sets for two distinct problems are incompatible with each other. This often means that sorting out and resolving these disconnects requires considering each patient’s distinct context.

In addition to problems, other recommendations for orders or documentation can be dependent on lab results and physical exam findings. If a patient has, for example, a low platelet count and evidence of internal bleeding, it may be appropriate to hold their blood thinner. And yet, from the perspective of a patient with a history or risk of life threatening clotting, holding their blood thinner may be exactly the wrong thing to do.

As more and more information is collected, both within individual encounters and across a longitudinal view for an individual patient, it will be necessary to sort things out. Where is the Washington Monument relative to the Lincoln Memorial when it’s known that the photos are accurate?

Today, such photos here can be electronically studied and compared to a satellite view showing both from where the photos were taken (shown in red circle below), as well as the actual locations and sizes of the structures on the Washington Mall.

In fact, nothing short of information technology would be capable of reliably and quickly combining all of the images into a single, coherent, useful picture. I think that the era of Meaningful Use will produce the equivalent in healthcare information as the EHR evolves. Developing our technology accordingly is exactly the perspective my team has taken to ensure electronic decision support helps clinicians make the right decisions. It’s a matter of patient safety and quality care.

What do you think?

Joe Bormel, M.D., MPH
CMO & VP, QuadraMed
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