capstone slide 5

Ed Wagner's Institute for Healthcare Improvement Chronic Care Model


As an afterthought, maybe this is not the best place to start from.

The CDC has a REACH program - Racial and Ethnic Approaches to Community Health -- Finding Solutions to Health Disparities 2007.

Within that is the program REACH Detroit Partnership.

Also, of potential interest, is the funding opportunity announcement from the CDC in this field although the closing date, May 7, 2007 is 6 days after this presentation is scheduled and might be a tad hard to reach.

The Johns Hopkins Bloomberg School of Public Health new department of Health, Behavior, and Society also represents the new way of looking at chronic care and lifestyle problems.
The 2006 Johns Hopkins Public Health Magazine on-line has an article "reach out to immigrants" with links to work being done at Hopkins in this area.

There are 20 or so 1-page articles there on "Urban Health" and all of them are relevant to this presentation and appear to me to be fully consistent with what I am suggesting here - so while my direction may be at odds with Wagner, it is aligned with Hopkins.

Also, the idea of using cell-phones to manage diabetes is not one of my own innovations. In fact, a recent JHU Division of Health Science Informatics seminar at Johns Hopkins was on a private company that is doing just that in Baltimore:
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February 23, 2007 10:45
Managing Diabetes by Cellphone

Suzanne Sysko, M.D., James Minor, Ph.D and Ryan Sysko (WellDoc)
***NO WEBCAST/VIDEO***
welldoc-communications

The technology link is clear to me, and under the covers the software is sophisticated (judging from their want-ads for software engineers), and I assume they are building an electronic record behind all that, but I don't know to what extent they are looking at team or group activities and using the phone as a collaboration tool, not a wireless data-processing device, and to what extent the patient is empowered, versus a data-entry clerk.

Those distinctions are the important innovative ones that this Capstone analysis contributes to the mix -- getting past using technology as a data-processing tool and looking to "technology-mediated collaboration" as the fertile ground for exploration and progress.
The focus has to be on the collaboration end, not on the technology end, to get this design to work, however -- making it very distinct from the approach most Electronic Health Record, or EMR, or PHR, or CPOE, or even the whole National Health Information Infrastructure is heading, which I think needs adjusting.

Lee Green, M.D., M.P.H., Professor and Associate Chair for Information Management int he Department of Family Medicine at the University of Michigan Medical School gave a seminar last week (Health Informatics Grand Rounds, April 18, 2007, contact health.information.grand.rounds@umich.edu) titled "Electronic Health Records: Solutions to the Right Problems?" where he similarly challenged the growing focus on a Computerized Physician Order Entry system as being the Holy Grail, saying "[EHRs] fare poorly at supporting system-based care, translation of evidence into practice, and quality improvement despite widespread belief in academic and policy circles that they provide these functions." A PR piece on Lee Green and type-2 diabetes is here.

It is important to note that I am not opposed to electronic health records or CPOE systems, provided they are designed with collaboration as the central design pillar, not an afterthought tacked on at the end. The technology for decent EMR's and CPOE with decision support has been around for over 30 years -- which I'm sure of because I was on a team that successfully ported Mass General's medical record system, in MUMPS, to multi-species use and put up 200 on-line terminals with sub-second response time in 1976 at Cornell University's Vet School, under the direction of John Lewkowitz.

ALL of the delays and obstacles since that time in human hospitals becoming similarly empowered have to be laid the doorstep of the social end of the socio-technology solution. That's why I'm so confident that solving technical problems of "interoperability" will not magically open the door to a flood of improved medical care.

To quote T.S. Eliot, my favorite author, who I notice is also quoted by the Software Engineering Institute's staff: T. S. Eliot noted, in Choruses from The Rock (1934):

They constantly try to escape
From the darkness outside and within
By dreaming of systems so perfect that no one will need to be good.
But the man that is shall shadow
The man that pretends to be.

After watching this field for 40 years, I am increasingly convinced that the core problems in the way of good medical care, and good health care, are spiritual problems, not technical problems. We have the technology, and have had it for 30 years. That is not the problem, and twiddling with it is not going to fix the problem.

We treat each other poorly, and that needs to be fixed. Then, the technology will matter. Until then, looking to technology for "solutions" will only rotate the problem and burn time and money and lives while Rome burns.

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