A Foundation for Evidence-Driven Practice A Rapid Learning System for Cancer Care: Workshop Summary (2010) / Chapter Skim
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6 Challenges and Opportunities
6 Challenges and Opportunities
Pages 49-68
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From page 49... ...
The survey also found that only about one out of ten hospitals has a basic EHR system with eight key functions fully deployed across all major clinical units. To spur efforts to computerize the nation's health records by 2014, Congress included in its American Recovery and Reinvestment Act two sections that together are called the "HITECH" Act.
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From page 50... ...
Initially, meaningful use will emphasize capturing and sharing data, but by 2013 a higher definition will emerge that emphasizes more advanced care processes, including sophisticated implementation of clinical decision support, which by 2015 will progress toward realization of improved outcomes through enhanced levels of technology. According to Friedman, meaningful use will likely not include the additional elements needed for a RLHS, including gridware, data stewardship, advanced intelligent methods, and means to aggregate information.
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From page 51... ...
Discussant Suanna Bruinooge of ASCO staff pointed out that ASCO, in conjunction with the NCI Center for Biomedical Informatics and Informational Technology and the NCI Community Cancer Centers Program (NCCCP) , has an initiative under way to specify the core informatics requirements, data element specifications, and EHR functions needed by practicing oncologists, paving the way for the development of oncology-specific products.
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From page 52... ...
State and Health Bank or Local Governments PHR Support Organization Community Health Centers SSA Community #1 VA Mobilizing Health Information Nationwide DoD Labs IHS CDC Integrated Pharmacies Delivery System Community #2 The Internet Standards, Specifications, and Agreements October 3, 2009 for Secure Connections IOM Cancer Forum FIGURE 6-1 The Nationwide Health Information Network. SOURCE: Friedman, 2009.
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From page 53... ...
We have to make building a quality observational system a cornerstone for a learning healthcare system." Dr. Edge noted that cancer registry problems are largely related to the quality and the timeliness of the data, and he stressed the need to enhance that quality by linking cancer registry data with administrative data, including payer claims, hospital data, and data from EHRs.
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From page 54... ...
Dr. Peter Bach of Memorial Sloan-Kettering Cancer Center reported a number of problems he had with data quality and completeness when he and his colleagues were engaged in the 2006 Medicare Oncology Demonstration Project, whose goal was to gather more information about patients and treatment patterns in routine cancer care.
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From page 55... ...
Dr. Sox suggested that to counter the problem of missing data, outcomes, and unmeasured confounders in the datasets taken from the records of actual patient care, data-gathering protocols should be established that detail what data physicians need to enter into the record and when, as well as systematic follow-up to ensure there are no missing data.
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From page 56... ...
Potosky said, it may validate those finding from observational studies, but sometimes there are no controlled clinical trials that are comparable. In addition, observational studies using cancer registry data may not consider certain variables that foster a selection bias.
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From page 57... ...
Dr. Neti stressed the need to have appropriate reporting standards so that the data collected can be used not only for evidence-based decision support and health care tailored to individual patients, but also to generate data that can be used for CER.
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From page 58... ...
Efforts are also under way to link cancer registry data to insurance claims data, state all-payers claims data, hospital discharge data, and provider office billing data. Other CDC initiatives have focused on standardization and harmonization of public health records.
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From page 59... ...
ENSURING PATIENT PRIVACY AND PORTABILITY OF MEDICAL RECORDS A major challenge in developing and implementing EHRs, computer grids, and other components of a RLHS is ensuring patient privacy and conformity to HIPAA rules, yet enabling portability of patient records, given that patients are increasingly being cared for at multiple institutions and access to patient data is needed for statistical analyses. With the proper computer hardware and software it is possible to de-identify patients or hide certain data items when patient data are used in the statistical analyses done by researchers.
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From page 60... ...
Dr. Sommer underscored the need for portable patient data, pointing out that chordoma patients often have multiple surgeries at multiple institutions and surgeons often cannot acquire the records of prior surgeries.
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From page 61... ...
Many of the CDC endeavors that Ms. Thames discussed aim to promote more rapid reporting of data by encouraging more standardized, machine-readable electronic health records.
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Dr. Wallace responded that "historical principles are still the right ones about peer review, patient protection, and generalizability.
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The capacity to provide highquality information for clinicians will ultimately make physician practices more efficient, and the use of decision support tools and their ilk can simplify the discussions doctors have with their patients.
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From page 64... ...
Others at the conference pointed out that the inadequate training community physicians often have in regards to clinical research limits their adequate participation. "Physicians think about an ‘n of 1' experience in terms of decision making, and they have been brainwashed a little bit to look at randomized clinical trials as the gold standard that leads to drug approvals.
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From page 65... ...
In some cases, IT applications actually increased the time providers spent on administrative tasks as opposed to providing direct patient care. With few exceptions, because the data collected were not used to provide clinicians with evidence-based decision support and feedback, or to link clinical care and research, clinicians generally did not see these electronic data as being useful to improve their clinical care.
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From page 66... ...
IT systems could then use this content, along with other relevant clinical information, to model a virtual patient and suggest and support holistic care plans used by multiple decision makers. Overarching Grand Challenge: Cognitive support RESEARCH PATIENT PATIENT CARE Where Medical Virtual clinicians Knowledge Patient want to stay Decision Support Medical Logic Clinical Transactions research Where transactions Health IT chains us Raw research Raw data data Workflow modeling and support, usability, cognitive support, computer-supported cooperative work (CSCW)
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From page 67... ...
CHALLENGES AND OPPORTUNITIES TABLE 6-1 Paradigm Shift Necessary for More Successful Computational Technology for Effective Health Care Old New One integrated set of data Sets of data from multiple sources Capture data in standardized Capture raw signal and annotate with standard terminology terminology Single source of truth Current interpretation of multiple, related signals Seamless transfer among systems Visualization of the collective output of relevant systems Clinician uses the computer to Clinician and patient work together with shared update the record during the records and information patient visit System provides transaction-level System provides cognitive support data Work processes are programmed People, process, and technology work together and adapted through as a system nonsystematic work-around SOURCE: Stead, 2009. Summarizing his approach to helping people think about electronic health records based on his experience, Dr.
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