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.