One of the challenges of being a physician in the 21st century is information overload. More medical literature is published every year than we can read in a lifetime. As electronic health records (EHRs) become more common, physicians can be overwhelmed with the data gathered about each patient. Physicians do not want to review hundreds of normal findings; they want to know what is actionable for each of their patients so as to keep them healthy.
Here’s an example. Suppose a patient’s blood pressure is 100/50. That’s data. Suppose that patient has a 10-year history of blood pressures of 150/100. That’s information. Suppose that the patient has a known history of coronary artery disease and is now experiencing chest pain. The sudden drop in blood pressure could indicate a serious myocardial infarction in progress. That’s knowledge. It’s time to give the patient an aspirin, oxygen, and nitrates immediately. That’s wisdom.
Recently, I asked my primary care physician to export my entire history from his EHR. Although I’m a completely healthy person, the result was a 77-page PDF. The document contains a mix of administrative and clinical data, numeric observations, and unstructured text. It would take a physician about an hour to navigate all these data.
How can we turn these data into information? Over the past few years, Beth Israel Deaconess’ clinical information systems team has built “event-driven medicine” into our applications. Events, such as medication changes, lab results, or newly discovered allergic reactions, generate data that can be transformed into actionable wisdom. Here are three examples:
Medication orders. When a physician writes for a medication at Beth Israel Deaconness, a query is sent to our regional data exchange to determine the patient’s insurance coverage for pharmaceuticals. Based on the answer, we access the appropriate payer-specific formulary so that all medications are preferentially chosen to minimize cost and maximize effectiveness for each patient. Every prescribed medication is checked against the entire history of the patient’s active medications from pharmacy and payer databases throughout the country. Safety issues, guidelines, and best practices are displayed to the clinician, ensuring quality care.
When the clinician selects the correct, safe medication in the right dose, the order is instantly routed to the pharmacy of the patient’s choice, going from the physician’s brain to the patient’s vein without any handwriting or human interpretation. All of this happens in real time based on the data found in EHRs, information about body function trends, knowledge from decision-support databases, and wisdom from the orchestration of all these moving parts behind the scenes via interoperable web services—ultimately providing the best choice for each medication written. This week, we just completed our one millionth medication processed this way.
Radiology tests. When a physician orders a radiology test at Beth Israel Deaconness, a query is sent to a decision-support engine which we co-developed with an analytics company. To select the most appropriate, evidence-based radiology test, the decision-support engine examines more than 1,000 best practice rules from the American College of Radiology and the world’s radiology literature, along with patient medications, laboratories, allergies, and demographics. Radiology exams are scored from five stars to one star, balancing efficacy, risk, and cost. If a clinician orders one of these tests, a pre-authorization is sent to the payer in real time and the test is automatically approved. All of this happens in a few seconds, using patient data plus the knowledge from the literature to yield a wise choice for radiology diagnostic testing. One hundred percent of high-cost radiology tests are processed this way.
Chronic care management. When a physician at Beth Israel Deaconness identifies a chronic disease condition, a decision-support “screening sheet” is created to track all the events in a patient’s care. Diabetic tracking includes lipids, glucose, eye exams, foot exams, hemoglobin A1-C, immunizations, and weight. Whenever an event occurs, such as a lab result or appointment, the screening sheet is updated and the decision-support rules recommend the best practices for diabetic care, filtering all these data into a concrete set of recommendations, such as “patient is past due for an eye exam.” Clinicians do not need to focus on the raw data, instead they can review suggestions in real time to optimize the care of the patient. This year, we achieved all our pay-for-performance goals using this approach.
Like many other projects, the pursuit of event-driven medicine is a journey. Over the next few years, we’ll continue our efforts to ensure that clinicians are given the real-time wisdom they need to deliver safe, cost effective, and appropriate care.
John D. Halamka, MD, MS, is CIO, Beth Israel Deaconess Medical Center, Boston, and chairman of the New England Healthcare Exchange Network (firstname.lastname@example.org). This column is reprinted with permission from his blog, Life as a Healthcare CIO.
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