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Thursday, March 6, 2014


Groan... Just what we need, another witty coinage of term. Recall "Rigorability?"
"I never make predictions, especially about the future."
- Casey Stengel

The benefits of modern medicine are clear. Lower infant mortality, longer life expectancy, a range of once killer diseases all but eradicated—fewer “therapeutic” leeches. But challenges? Yes, there are still plenty of those too.

In a recent conversation, Dr. Daniel Kraft, Faculty Chair for Medicine and Neuroscience at Singularity University, stated that the US spends some 18% of gross domestic product on healthcare and yet, according to a 2013 report, ranks 17th on a list of 17 developed countries by outcome.

Even as more patients sign up for insurance, he says, there is a growing shortage of providers, particularly in primary care. And in light of millions of aging baby boomers and rising obesity rates, the US healthcare burden is set to grow more burdensome.

In the very broadest terms, Kraft believes the current system focuses too much on what he calls “sick” care and not enough on “health” care. We incentivize the medical system and doctors to put patients in hospitals and to do procedures after they’re sick, instead of rewarding simpler measures to prevent illness early on.
For much of history, medicine had to be reactive, to focus on fixing patients, because the causes of disease were largely unknown. But that’s less true these days.
Kraft says, “We’re on the cusp of rethinking and reinventing healthcare given the financial pressures, the demographic pressures, and the power and lowering price-point of many emerging technologies that are getting smaller, faster, cheaper, and smarter—which, especially when combined and layered upon each other, have dramatic potential to positively impact health and biomedicine.”...
The better we know our own bodies—and can integrate, analyze, and understand the trends—the more we are empowered to own our own health and the earlier we can catch and prevent anomalies, something Kraft calls “predictalytics.”...
Read on.

Notwithstanding the goofy new term "predictalytics" (expect it to be capitalized and followed by ™or ® shortly, just like "Lean Startup®"), I agree with the observations about the current state of the U.S. healthcare space. None of them are exactly news.

What's not to love? Patient engagement? Proactive "ownership" of one's wellness?
The big picture, according to Kraft?

Accelerating information technologies, merging with smaller and more powerful diagnostics, sensors and devices are bleeding into health and medicine—an area where they are sorely needed and have the opportunity to improve millions of lives. “We’re moving from a world of intermittent and reactive to continuous and proactive,” Kraft says.
Color me a believer -- in principle. Nonetheless, "improving millions of lives" is a tall order, one going well beyond health tech and (the chronically shaky) PPACA reforms. Recall my January post
When it comes to health, your zip code matters more than your genetic code.

Are EHRs at a 'tipping point'?
With implementations past critical mass, AHIMA takes stock
CHICAGO | March 6, 2014

With more than 50 percent of practices and 80 percent of hospitals having adopted electronic health records and attested for meaningful use by now, it's time to talk about next steps.

The March edition of the Journal of AHIMA does just that, with a story that looks at the changes and challenges ahead for health information management professionals as EHRs become a fact of life.

“We have reached a tipping point in adoption of electronic health records,” said Health and Human Services Secretary Sebelius in May 2013. “More than half of eligible professionals and 80 percent of eligible hospitals have adopted these systems, which are critical to modernizing our health care system.”

Now that the plumbing has been installed, the next step is making the water flow.

Or, as the article's author Mary Butler finds, perhaps telecommunications offers a better analogy.

"If you buy a telephone, it’s only as good as the other people who have telephones and can call," Judy Murphy, RN, deputy national coordinator for programs and policy at the Office of the National Coordinator for Health IT tells AHIMA. "One of the things we’re doing with getting EHRs installed is that we’re setting up the capabilities and electronically exchanging the information so we can create a patient-centric record.”...
Indeed. For purposes of patient-centric "Predictalytics®."

Seriously, is the current batch of ONC CHPL Certified EHRs already at a "tipping point" of obsolescence, irrelevance? Still fighting the last war? Will personalized #mHealth of the sort proffered by the futurist folks at SingularityHUB render today's EHRs the equivalent of the BetaMax and 8-track?

What do you think?

So, what of this "Singularity" stuff?

See also "Technological Singularity." Good discussion of the concepts and the controversies. "Exceeds my Scope."

"It’s time for PCMH advocates to travel back through the looking glass and re-engineer the PCMH to thrive in the real world."
- Michael Millenson
I'll be interested to hear Doc Gurley's reaction to this article.

Biomarker Profiling by Nuclear Magnetic Resonance Spectroscopy for the Prediction of All-Cause Mortality: An Observational Study of 17,345 Persons


Early identification of ambulatory persons at high short-term risk of death could benefit targeted prevention. To identify biomarkers for all-cause mortality and enhance risk prediction, we conducted high-throughput profiling of blood specimens in two large population-based cohorts.

Methods and Findings 

106 candidate biomarkers were quantified by nuclear magnetic resonance spectroscopy of non-fasting plasma samples from a random subset of the Estonian Biobank (n = 9,842; age range 18–103 y; 508 deaths during a median of 5.4 y of follow-up). Biomarkers for all-cause mortality were examined using stepwise proportional hazards models. Significant biomarkers were validated and incremental predictive utility assessed in a population-based cohort from Finland (n = 7,503; 176 deaths during 5 y of follow-up). Four circulating biomarkers predicted the risk of all-cause mortality among participants from the Estonian Biobank after adjusting for conventional risk factors: alpha-1-acid glycoprotein (hazard ratio [HR] 1.67 per 1–standard deviation increment, 95% CI 1.53–1.82, p = 5×10−31), albumin (HR 0.70, 95% CI 0.65–0.76, p = 2×10−18), very-low-density lipoprotein particle size (HR 0.69, 95% CI 0.62–0.77, p = 3×10−12), and citrate (HR 1.33, 95% CI 1.21–1.45, p = 5×10−10). All four biomarkers were predictive of cardiovascular mortality, as well as death from cancer and other nonvascular diseases. One in five participants in the Estonian Biobank cohort with a biomarker summary score within the highest percentile died during the first year of follow-up, indicating prominent systemic reflections of frailty. The biomarker associations all replicated in the Finnish validation cohort. Including the four biomarkers in a risk prediction score improved risk assessment for 5-y mortality (increase in C-statistics 0.031, p = 0.01; continuous reclassification improvement 26.3%, p = 0.001).

Biomarker associations with cardiovascular, nonvascular, and cancer mortality suggest novel systemic connectivities across seemingly disparate morbidities. The biomarker profiling improved prediction of the short-term risk of death from all causes above established risk factors. Further investigations are needed to clarify the biological mechanisms and the utility of these biomarkers for guiding screening and prevention.
Nice. Lots of pretty interesting and thorough biostats in the paper. If you seemed healthy by all conventional metrics and got a high score on this assay, you'd be pretty anxious -- as would be the issuer of your life insurance policy.

I rather doubt that NRM Spectroscopy will be showing up as a downloadable app for your smartphone anytime soon for Personalized Predictalytics®. It's expensive.




"I am pretty monomaniacally interested in workflow. Because workflow is a series of steps, each of which consumers a resource (a cost), and achieves some goal, that the value. Health IT need more success in this area."
My summary Visualization 101 of workflow:

Doesn't matter how large, fine-grained or otherwise nominally "complex"
a workflow is, the sequential and parallel steps all boil down to this logic.

Very interesting blog post by Chuck. He takes things to a much more sophisticated level than is commonly thought of when we hear or read the word "workflow."
“Pragmatic interoperability (PI) is the compatibility between the intended versus the actual effect of message exchange.” (ref) The best current practical candidate for achieving pragmatic interoperability is workflow technology. A candidate for measuring progress toward pragmatic interoperability in healthcare is diffusion of workflow technology into healthcare...
To understand pragmatic interoperability, you must also understand syntactic and semantic interoperability. Syntax, semantics, and pragmatics are ideas from linguistics. You can think of language as being built from successive layers of information processing: phonetics, phonology, morphology, syntax, semantics, pragmatics, and discourse (conversation) ... Turns out linguistics is relevant to communication among health IT systems too — who da thunk!

Between healthcare IT systems, as between people, interoperability is ultimately more about conversation than mere message-passing transactions. Think about it. Think about how self-correcting conversation is. How much conversation depends on shared understanding of shared context...
Healthcare desperately needs usable interoperability. We need interoperability at the level of user interface, user experience, provider and patient experience and engagement, not just syntactic and semantic interoperability. The best metaphor at this level of interoperability is conversation, not transaction. But we need pragmatic interoperability to get to conversational interoperability. And workflow tech is the best way to engineer self-repairing conversations among pragmatically interoperable health IT systems...

Communication among EHRs and other health IT systems must become more “conversational,” if they are to become more resistant to errorful interpretation...
Plug-and-play syntactic and semantic interoperability is currently the holy grail of EHR interoperability. We hear less about the next level up: pragmatic interoperability. As soon as, and to the degree that, we achieve syntactic and semantic interoperability among, issues of pragmatic interoperability will begin to dominate. And they will manifest themselves as issues about coordination among EHR workflows. In fact, issues of pragmatic interoperability are already beginning to arise, although they are not always recognized as such...
Quite intriguing. I've not really given much thought to topics such as "pragmatics" and "semiotics" since grad school, certainly not in connection with issues of workflow and "interoperability."

Chuck continues:
Whatever else Meaningful Use has done, many proponents and opponents would agree, it’s created a multi-billion dollar industry of EHR “work-arounds.” From EHR-extenders to speech recognition interfaces to full-blown workflow platforms riding on top of EHRs and related systems, workflow infrastructure, which ideally should have been implemented in the first place, is being added piecemeal. It’s flowing around legacy systems, talking to them through APIs when available, through reverse-engineered interfaces when not. Pragmatic interoperability provides users the “What’s next?” that many current systems can’t.

Social, mobile, analytics, and cloud (SMAC) get glory and credit. But often, under the hood, is workflow technology: workflow engines, process definitions, graphical editors and workflow analytics. Some EHRs will fare better than other. EHRs with open APIs will become plumbing. EHRs relying on workflow tech themselves will more naturally meet pragmatic interoperability half-way. Or one-quarter or three-quarter way, depending on their own degree of process-aware architecture and infrastructure...
Good stuff. Mr. Webster is definitely a heavy hitter, a SME. I have new nuances to reflect upon with respect to workflow and "interoperability." My thinking has yet to explicitly address the higher-level considerations pertaining to "pragmatics."

I reach immediately for me Photoshop CS6.

Another visual, one I did in SmartDraw while at the REC (wish they would put out a Mac version):

"The sum of your process flow charts IS your Org Chart." 
  - Brent James, MD, M.Stat
Dr. James proffered that during our 1994 IHC healthcare CQI training. I am always reminded of it. Notwithstanding that most organizations continue to obsess over the tired traditional vertical command-and-control reporting-lines org charts, he's right.

Another of my workflow model visuals (also a SmartDraw rendering):


More to come...

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