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Transcript of Brazos Family Medicine Residency Retreat Nancy W. Dickey Leadership in Medicine Lecture James L....
Brazos Family Medicine Brazos Family Medicine Residency RetreatResidency Retreat
Nancy W. Dickey Leadership in Nancy W. Dickey Leadership in Medicine Lecture Medicine Lecture
James L. Holly, MDJames L. Holly, MD
CEO, SETMA, LLPCEO, SETMA, LLP
www.setma.comwww.setma.com
April 25, 2008April 25, 2008
Knowledge and PracticeKnowledge and Practice
Acquiring and applying medicine’sAcquiring and applying medicine’s
complex knowledge basecomplex knowledge base
effectively will require aeffectively will require a
fundamental shift in physicianfundamental shift in physician
approach to information.approach to information.
EMR Creates OpportunityEMR Creates Opportunity
Electronic medical records providesElectronic medical records provides
the means for that shift but does notthe means for that shift but does not
dictate that such a shift will takedictate that such a shift will take
place.place.
Often EMR used as a glorified Often EMR used as a glorified transcription tool without:transcription tool without:
Providing significant advantages Providing significant advantages in processing informationin processing information
Patients profiting from sound Patients profiting from sound science.science.
The Fifth DisciplineThe Fifth Discipline
Peter Senge addresses “Peter Senge addresses “systemssystems
thinkingthinking” which applies to health” which applies to health
care delivery via an electroniccare delivery via an electronic
format as legitimately as it appliesformat as legitimately as it applies
to other business enterprises.to other business enterprises.
Senge states:Senge states:
““Learning has come to beLearning has come to be
synonymous with ‘taking insynonymous with ‘taking in
information’…(which) is onlyinformation’…(which) is only
distantly related to real learning.”distantly related to real learning.”
““System thinking needed becauseSystem thinking needed becausehumankind has the capacity to:humankind has the capacity to:
Create more information than Create more information than anyone can absorbanyone can absorb
Foster greater interdependency Foster greater interdependency than anyone can managethan anyone can manage
Accelerate change faster than Accelerate change faster than anyone’s ability to keep pace.”anyone’s ability to keep pace.”
““Complexity can undermineComplexity can undermineconfidence and responsibility.”confidence and responsibility.”
Confidence is undermined when the Confidence is undermined when the
vastness of available, valuable andvastness of available, valuable and
applicable information is such thatapplicable information is such that
it appears futile to the individual toit appears futile to the individual to
try and “keep up.”try and “keep up.”
Responsibility SurrenderedResponsibility Surrendered
Without confidence, responsibilityWithout confidence, responsibility
is surrendered as healthcareis surrendered as healthcare
providers tacitly ignore bestproviders tacitly ignore best
practices, substituting experience aspractices, substituting experience as
a decision-making guide.a decision-making guide.
Senge argues:Senge argues:
““Systems thinking is the antidote toSystems thinking is the antidote to
this sense of helplessness that manythis sense of helplessness that many
feel, as we enter the ‘age offeel, as we enter the ‘age of
interdependence.’”interdependence.’”
In healthcare the solution toIn healthcare the solution tohelplessness is to “see” the:helplessness is to “see” the:
Interrelatedness of one disease Interrelatedness of one disease aggravating or precipitating aggravating or precipitating anotheranother
dynamic interaction between the dynamic interaction between the treatments of simultaneous treatments of simultaneous pathological processes.pathological processes.
Systems thinking and HealthSystems thinking and Health
Systems-thinking and the dataSystems-thinking and the data
display designed on thosedisplay designed on those
principles allow the provider toprinciples allow the provider to
““see” how the treatment of onesee” how the treatment of one
disease augments the treatment ofdisease augments the treatment of
another.another.
Medical Knowledge BaseMedical Knowledge Base
4,000-7,000 medically-related4,000-7,000 medically-related
journals published. journals published. Over 1,000 medically-related Over 1,000 medically-related
journal articles published each journal articles published each day.day.
Primary Care LiteraturePrimary Care Literature
““How Much Effort is needed to keep upHow Much Effort is needed to keep upwith the literature relevant to primary care?”with the literature relevant to primary care?”
341341 journals relevant to primary care. journals relevant to primary care. 7,2877,287 articles published monthly articles published monthly 627.5627.5 hours per month to read and hours per month to read and
evaluate these articles.evaluate these articles. (722 hours in a month) (722 hours in a month)
1997: Medical Articles 1997: Medical Articles
The British Medical Journal:The British Medical Journal:
Over 10,000,000 Medical articlesOver 10,000,000 Medical articles
on library shelveson library shelves 1/3rd are indexed in the National1/3rd are indexed in the National
Library of Medicine MedlineLibrary of Medicine Medline
Dr. Archie Cochrane opined:Dr. Archie Cochrane opined:
““It is surely a great criticism of ourIt is surely a great criticism of our
profession that we have notprofession that we have not
organized a critical summary…organized a critical summary…
adapted periodically, of all relevantadapted periodically, of all relevant
randomized controlled trials.”randomized controlled trials.” (1997)(1997)
Cochrane CentersCochrane Centers
15 Cochrane Centers today 15 Cochrane Centers today 1,098 complete reviews1,098 complete reviews 866 protocols (reviews in 866 protocols (reviews in
progress)progress)
It is estimated that it will take 30 years to complete reviewsIt is estimated that it will take 30 years to complete reviewsOn random-controlled studies (RCTs) in all fields ofOn random-controlled studies (RCTs) in all fields ofmedicine which presently exist.medicine which presently exist.
Knowledge and AccessKnowledge and Access
Without medical knowledge, quality-of-careWithout medical knowledge, quality-of-careinitiatives will falter, but the volume ofinitiatives will falter, but the volume ofmedical knowledge is so vast that it canmedical knowledge is so vast that it canoverwhelm healthcare providers.overwhelm healthcare providers.
The good news: the state of our currentThe good news: the state of our currentknowledge is excellent. The bad news: theknowledge is excellent. The bad news: theform in which that knowledge is stored.form in which that knowledge is stored.
MetanoiaMetanoia: Change required: Change required
““The most accurate word…toThe most accurate word…to
describe what happens in a learningdescribe what happens in a learning
organization is “metanoia.’ Itorganization is “metanoia.’ It
means a shift of mind…To graspmeans a shift of mind…To grasp
(this) is to grasp the deeper(this) is to grasp the deeper
meaning of ‘learning,’.”meaning of ‘learning,’.”
Challenges to changeChallenges to change
To create excellence in healthcare,To create excellence in healthcare,
which is more of a process than awhich is more of a process than a
product, providers must continually beproduct, providers must continually be
““learning.,” which will require a changelearning.,” which will require a change
in the understanding of the nature ofin the understanding of the nature of
learning and will also require thelearning and will also require the
elimination of barriers to learning. elimination of barriers to learning.
Learning DisabilitiesLearning Disabilities
““Learning disabilities” afflictLearning disabilities” afflict
organizations or disciplines attemptingorganizations or disciplines attempting
to make this shift.to make this shift.
These prevent organizations or individualsThese prevent organizations or individuals
from making the changes which would alterfrom making the changes which would alter
outcomes and increase effectiveness.outcomes and increase effectiveness.
Fixation on EventsFixation on Events
This disability results because we become This disability results because we become
mesmerized with things which occur rathermesmerized with things which occur rather
than looking at their cause.than looking at their cause.
Events occur suddenly and demand ourEvents occur suddenly and demand our
attention, while the processes which provideattention, while the processes which provide
the leverage for effecting change are subtlethe leverage for effecting change are subtle
and occur slowly over time.”and occur slowly over time.”
Linear Thinking and EventsLinear Thinking and Events
In a biological system, this is also true. TheIn a biological system, this is also true. ThePrimary threat is not the heart attack but thePrimary threat is not the heart attack but theweight gain, the inactivity, the cigaretteweight gain, the inactivity, the cigarettesmoking, and the cholesterol.smoking, and the cholesterol.
Linear thinking focuses on the event and notLinear thinking focuses on the event and notThe long-standing problems which causedThe long-standing problems which causedin the event.in the event.
Parable of the Boiled FrogParable of the Boiled Frog
““Learning to see slow, gradualLearning to see slow, gradual
processes requires slowing downprocesses requires slowing down
our frenetic pace and payingour frenetic pace and paying
attention to the subtle as well as theattention to the subtle as well as the
dramatic.”dramatic.”
Slow “Boiling” creates learning Slow “Boiling” creates learning disabilitydisability
The slow “boiling” which comesThe slow “boiling” which comes
from the deterioration of healthfrom the deterioration of health
requires a new methodology forrequires a new methodology for
effecting change in patient andeffecting change in patient and
provider behaviorprovider behavior..
Creating Discomfort in PatientCreating Discomfort in Patient
Patient change will be achieved byPatient change will be achieved by
enhancing the capability of aenhancing the capability of a
Provider to create discomfort in theProvider to create discomfort in the
patient in order to effect changepatient in order to effect change
which will benefit the patient in thewhich will benefit the patient in the
long run.long run.
Creating Discomfort in ProviderCreating Discomfort in Provider
Creation of discomfort in theCreation of discomfort in the
provider via self-auditing at theprovider via self-auditing at the
point of care allowing the providerpoint of care allowing the provider
to measure his/her performanceto measure his/her performance
against an accepted standard.against an accepted standard.
Data Display Creates DiscomfortData Display Creates Discomfort
Because the processes which ultimately Because the processes which ultimately destroy health are painless and invisible,destroy health are painless and invisible,effective intervention requires making thoseeffective intervention requires making thoseprocesses “felt.” processes “felt.”
Data display which is longitudinal and Data display which is longitudinal and comparative can create discomfort in thecomparative can create discomfort in thepatient and provider which can contribute topatient and provider which can contribute tochange.change.
Delusion of Delusion of Learning from ExperienceLearning from Experience
The slow change in systems, particularlyThe slow change in systems, particularly
Biological systems, make it impossible toBiological systems, make it impossible to
associate personal experience with effectiveassociate personal experience with effective
treatment.treatment.
Treatment based on personal observationTreatment based on personal observation
be inadequate as the consequences are seenbe inadequate as the consequences are seen
long after the intervention.long after the intervention.
Learning From ExperienceLearning From Experience
Learning from experience resultsLearning from experience results
not only in very slow change innot only in very slow change in
patient care but also results inpatient care but also results in
reluctance by providers to makereluctance by providers to make
changes which will benefit patients.changes which will benefit patients.
““Treatment inertia”Treatment inertia”
““Lack of treatment intensification Lack of treatment intensification in a patient not at evidence-based in a patient not at evidence-based goals for care.”goals for care.”
““Learning disabilities” prevent a Learning disabilities” prevent a healthcare organization from healthcare organization from adopting a learning culture.adopting a learning culture.
Core of Systems Thinking.Core of Systems Thinking.
Shift of mind which is fundamental to learning Shift of mind which is fundamental to learning
more even than memorizing new information:more even than memorizing new information:
Requires focusing upon the slow processes Requires focusing upon the slow processes which cause deterioration in biological systemswhich cause deterioration in biological systems
Requires willingness to subject personal Requires willingness to subject personal experience to critique of evidenced-based care.experience to critique of evidenced-based care.
Summarizing systems thinkingSummarizing systems thinking
““It is a discipline of seeing wholesIt is a discipline of seeing wholes
……a framework for seeinga framework for seeing
Interrelationships rather than thingsInterrelationships rather than things
and patterns of change rather thanand patterns of change rather than
static ‘snapshots.’”static ‘snapshots.’”
Medical Records are SnapshotsMedical Records are Snapshots
Historically, medical records have beenHistorically, medical records have beensnapshotssnapshots of a patient’s condition without of a patient’s condition withoutconnection between the past and the future.connection between the past and the future.
EMR has the potential of providing aEMR has the potential of providing alongitudinallongitudinal portraitportrait of the patient where of the patient wherepatterns and directions of change can bepatterns and directions of change can beviewed.viewed.
Design of tools for changeDesign of tools for change
The medical application of these conceptsThe medical application of these concepts
provides a framework for the design of toolsprovides a framework for the design of tools
used to change the behavior of patients andused to change the behavior of patients and
physicians, and to shift from information andphysicians, and to shift from information and
experience to evidenced-based outcomes andexperience to evidenced-based outcomes and
data analysis over time.data analysis over time.
““Dynamic Complexity”Dynamic Complexity”
The final systems-thinking concept guidingThe final systems-thinking concept guiding
the design of an EMR which will:the design of an EMR which will:
Facilitate active learningFacilitate active learning Avoid learning disabilitiesAvoid learning disabilities Result in dynamic data managementResult in dynamic data management Change physician and patient behaviorChange physician and patient behavior
Point of LeveragePoint of Leverage
Most healthcare analysis focuses uponMost healthcare analysis focuses upon
multiple variables and a plethora of data.multiple variables and a plethora of data.
This is “This is “detail complexitydetail complexity.”.”
The greatest opportunity for effectingThe greatest opportunity for effecting
change in an organization or an organism ischange in an organization or an organism is
in what Senge calls “in what Senge calls “dynamic complexitydynamic complexity.”.”
““Dynamic Complexity”Dynamic Complexity”
This occurs when “cause and effect are subtle, andThis occurs when “cause and effect are subtle, and
where the effects over time of interventions are notwhere the effects over time of interventions are not
obvious.”obvious.”
The applications to medical research design areThe applications to medical research design are
intriguing but beyond this discussion, but “the realintriguing but beyond this discussion, but “the real
leverage in most management situations lies inleverage in most management situations lies in
understanding “dynamic complexity.”understanding “dynamic complexity.”
Data DisplayData Display
Data display can obscure effective Data display can obscure effective
management if it simply presentsmanagement if it simply presents
more detail while ignoring, ormore detail while ignoring, or
further obscuring, the dynamicfurther obscuring, the dynamic
interaction of one part of ainteraction of one part of a
biological system with another.biological system with another.
Circular ComplexityCircular Complexity
The circle describes a biologicalThe circle describes a biological
system much more effectively thansystem much more effectively than
a straight line.a straight line.
Yet, most medical data is displayedYet, most medical data is displayed
in a linear fashion.in a linear fashion.
Seeing Circles of CausalitySeeing Circles of Causality
““Reality is made up of circles, but we seeReality is made up of circles, but we see
straight lines…Western languages…arestraight lines…Western languages…are
Biased toward a linear view. If we want toBiased toward a linear view. If we want to
see system-wide interrelationships, we needsee system-wide interrelationships, we need
a language of interrelationships, a languagea language of interrelationships, a language
of circles.”of circles.”
((The Fifth DiscipleThe Fifth Disciple))
Application of Application of Fifth DisciplineFifth Discipline
It is here that we see the applicationIt is here that we see the application
of of The Fifth DisciplineThe Fifth Discipline to medical to medical
information technology. Theseinformation technology. These
seven concepts derive fromseven concepts derive from
systems-thinking principles:systems-thinking principles:
Systems Thinking: Systems Thinking: Application OneApplication One
Healthcare delivery is not improvedHealthcare delivery is not improved
simply by the providing of more simply by the providing of more
information to the healthcareinformation to the healthcare
provider at the point of care.provider at the point of care.
Systems Thinking: Systems Thinking: Application TwoApplication Two
Healthcare is improved when the organization ofHealthcare is improved when the organization of
information creates a dynamic interaction betweeninformation creates a dynamic interaction between
the provider, the patient, the consultant and allthe provider, the patient, the consultant and all
other members of the healthcare team, as wellother members of the healthcare team, as well
as creating the simultaneous integration of that dataas creating the simultaneous integration of that data
across disease processes and across provideracross disease processes and across provider
perspectives, i.e., specialties. perspectives, i.e., specialties.
Systems Thinking:Systems Thinking:Application ThreeApplication Three
Healthcare delivery is not necessarily improvedHealthcare delivery is not necessarily improved
when an algorithm for every disease process iswhen an algorithm for every disease process is
produced and made available on a handheldproduced and made available on a handheld
pocket computer device but it is improved when pocket computer device but it is improved when
the data and decision-making tools are structuredthe data and decision-making tools are structured
and displayed in a fashion which dynamicallyand displayed in a fashion which dynamically
changes as the patient’s situation and needchanges as the patient’s situation and need
change.change.
Systems Thinking:Systems Thinking:Application FourApplication Four
Healthcare delivery also improves when dataHealthcare delivery also improves when data
and information processed in one clinicaland information processed in one clinical
setting are simultaneously available in all setting are simultaneously available in all
settings. This improvement does not onlysettings. This improvement does not only
result from efficiency but from the impactresult from efficiency but from the impact
the elements contained in that data set exertthe elements contained in that data set exert
upon multiple aspects of a patient’s health.upon multiple aspects of a patient’s health.
Systems Thinking:Systems Thinking:Application FiveApplication Five
Healthcare is improved when evaluation ofHealthcare is improved when evaluation of
the quality of care as measured bythe quality of care as measured by
evidenced-based criteria is automaticallyevidenced-based criteria is automatically
determined at the point of. Healthcare isdetermined at the point of. Healthcare is
improved when the data display makes it improved when the data display makes it
simple for the provider to comply withsimple for the provider to comply with
the standards of care, if the evaluationthe standards of care, if the evaluation
demonstrates a failure to do so.demonstrates a failure to do so.
Systems ThinkingSystems ThinkingApplication SixApplication Six
Healthcare Healthcare is also improvedis also improved when data can be when data can bedisplayed longitudinally, demonstrating to thedisplayed longitudinally, demonstrating to thepatient over time how their efforts have affectedpatient over time how their efforts have affectedtheir global well-being.their global well-being.
This is circular rather than linear thinking. AThis is circular rather than linear thinking. Aperson begins at health. Aging and habits resultperson begins at health. Aging and habits resultin the relative lack of health. Preventive carein the relative lack of health. Preventive careand positive steps preserve, or restore health.and positive steps preserve, or restore health.
Systems ThinkingSystems ThinkingApplication SevenApplication Seven
Healthcare improvement viaHealthcare improvement via
systems will require dynamicsystems will require dynamic
auditing tools giving providers andauditing tools giving providers and
patients immediate feedback on thepatients immediate feedback on the
effectiveness of their healthcare.effectiveness of their healthcare.
If excellent healthcare requiresIf excellent healthcare requireshealthcare organizations to:healthcare organizations to:
BBe “learning organizations”e “learning organizations” Avoid “learning disabilities”Avoid “learning disabilities” Think in a circular rather than a Think in a circular rather than a
linear fashionlinear fashion Look at dynamic complexity Look at dynamic complexity
rather than detail complexityrather than detail complexity
If health science has the capacity:If health science has the capacity:
To create far more information than To create far more information than anyone can absorb,anyone can absorb,
To foster far greater interdependency To foster far greater interdependency than anyone can managethan anyone can manage
To accelerate change far faster than To accelerate change far faster than anyone’s ability to keep pace.anyone’s ability to keep pace.
EMR PowerEMR Power
How can electronic patient records and/or How can electronic patient records and/or
electronic patient management help solveelectronic patient management help solve
these problems and make it possible forthese problems and make it possible for
healthcare providers to remain current andhealthcare providers to remain current and
fulfill their responsibility of caring forfulfill their responsibility of caring for
patients with the best treatments available?patients with the best treatments available?
Linear ThinkingLinear Thinking
Circular CausalityCircular Causality
Data flow to and from the patient’s coreData flow to and from the patient’s coreinformation, and to and from interactiveinformation, and to and from interactivedisease management capabilities:disease management capabilities:
Acute condition dataAcute condition data
Longitudinal dataLongitudinal data
Standards of care which reflect a positive state of Standards of care which reflect a positive state of
healthhealth
Automatically-populated-treatment reflecting best Automatically-populated-treatment reflecting best
practices based on random controlled trialspractices based on random controlled trials
Auditing tools which reflect provider excellenceAuditing tools which reflect provider excellence
Automatically-populated-patient follow-up instructions Automatically-populated-patient follow-up instructions
Automatically-created-patient educationAutomatically-created-patient education
Can this be done? Can this be done? What would it look like?What would it look like?
While Southeast Texas Medical Associates’ While Southeast Texas Medical Associates’
EMR Data Base, which is built onEMR Data Base, which is built on
NextGen’s platform, is not perfect, it is aNextGen’s platform, is not perfect, it is a
significant step forward in addressingsignificant step forward in addressing
healthcare delivery utilizing healthcare delivery utilizing Fifth DisciplineFifth Discipline
principles.principles.