While at Massachusetts General Hospital last week, as a guest of The Stoeckle Center for Primary Care Improvement, I was invited to meet the team at the Laboratory of Computer Science based at MGH. The Lab of Computer Science produces the OnCall series of clinical web portals, which are a front end to the Computer Stored Ambulatory Record medical record system.

The reason it is a “series” and not “a front end” is because this system actually has brands that are specific to the specialties and care that it supports. Here’s a picture from a computer screen that shows them:

Over at one of my favorite blogs, e-patients.net, e-Patient Dave is starting a dicussion about what Health 2.0 “is;”: e-patients: Participate in defining “Health 2.0″

I started things off with a definition based on one created by The Economist, which I’ll repeat here:

Health 2.0 is the transition to personal, participatory health care. Everyone is invited to see what is happening in their own care and in the health care system in general, to add their ideas, and to make it better every day.

Feel free to suggest your improvements here, or there. I enjoy the idea that patients like Dave and readers of e-Patients will create improvements that can be incorporated.

If someone asked you, “What is Health 2.0?” Would you feel comfortable answering with the definition above? If not, how would you change it? Be sure if you would to tell a little bit about “why?” The story of how we get here is as important as the where we got to.

Osborn RF. GE and UNIVAC: Harnessing the High-Speed Computer. Harvard Business Review. 1954;32(4):99-107. [Accessed March 15, 2008]. If you do not have access to a database that hosts this article, you can look at this one.

I feel so unoriginal, and yet enlightened at the same time.

In my ongoing interest to understand where we came from, so we can move ahead, I was alerted to this article while reading The Big Switch: Rewiring the World, from Edison to Google (review coming soon), and had to read it. It has enough quotable quotes to fill 10-20 different presentations on health information technology, because a lot of what we’ve done has happened before. Just begin with the opening:

How soon the first complete electronic accounting system can be seen depends not on the business machine companies, and not on the engineers, but on the controllers themselves.

The article was written by the Manager of the Business Procedures Section at General Electric’s Louiseville plant, describing how General Electric would decide to spend almost $1 million on a tool that had never been deployed in business - the computer.

In the discussion, the fears and promise of an entire information technology industry are presented. Everything from the maverick nature of IT professionals (businesses not embracing this technology were referred to as “Rip Van Winkle”-esque, asleep to the future), to the desire to integrate the tool into ongoing operations:

…we should avoid both the deadening effect of all the limitations that are so often attributed to electronic computers and the frightening requirement of “rethinking entire operations” according to the prescription of so many of the experts of the subject.

That’s a challenging notion - we talk today about rethinking health care processes in anticipation of health information technology implementation. How successful are we at doing that? This paper gives clues that we came from a place where the bias was not to rethink things.

There are other fears presented, each managed by the GE team, including that an entire “electronic brain” would take over the decision making of executives. The computer was deliberately not put in a position to do more than provide information and speed repetitive tasks.

There is also the beginning of the personalization of the computer. UNIVAC is referred to as a person, even a baby, when the author says that it will be tended to and “nursed” by the data centers that will support it. I think we still live with that notion today, that a computer is a person, which generates various emotions among its users.

The article provides a lot of thinking for what the hopes were and whether they were met. In some ways, business went too far, by automating too much. LEAN students like myself are working to dismantle automation in many cases - more databases does not yield more understanding we have now found. The article also failed to predict the impact of the information technology infrastructure that would have to be developed to support this utopia - up to 45 % of capital costs of some companies in the last decade.

One thing that resonated with me (of course) was the emphasis on optimism in the leaders that would enter this new industry. For the leadership of their new computer group, they sought someone with

…enthusiasm, vision, foresight, energy, and an optimistic point of view; he [sic] should be willing to take risks and to devote his entire energies and thoughts to the task at hand.

Is Health Information Technology 2008 equal to General Electric 1954? A little. At the same time, it’s nice to hear that optimism has not gone out of style. It’s always worth looking at our past in the interest of saving some time for the future.

Concidentally, I ran across this post on fellow physician Jay Parkinson, MD’s blog, which also harkens back to a future once dreamed of.

[Note: The article is copyrighted and as far as I can tell, not available for purchase on the Harvard Business Review web site. I have linked instead to another article about the GE UNIVAC purchase]

I came across Susannah Fox’s recent blog entry: (e-patients: Flashback to 2001) where she uploaded a PDF of the American Medical Association’s Press Release of Resolutions for 2001 (you can link to it directly here), which included a resolution to “trust your doctor, not a chat room.”

She said she posted it by the popular demand (of one), but I also was glad she posted it (so increase the count to two, Susannah!), and followed the link to another blog post that was critical of her presentation at the Health 2.0 conference. In that post, the author said, “is Fox actually disagreeing with those who think it wiser to seek advice from physicians than to take seriously medical advice received from anonymous strangers in internet chat rooms?” and I wanted to comment on this as someone sitting in the audience (and who got to catch up with Susannah shortly before she went on stage - ok, so I am disclosing that I am a fan).

I think what Susannah was responding to, and somewhat verified in David Rothman’s post is the binary-ness of the argument, that it’s either your doctor or the Internet, not both. The first question I ask when I wonder about behavior is (in true LEAN tradition) “why?” Why would a patient access information outside of their physician relationship? We can guess at many reasons, including that they don’t have access to a doctor, or the doctor they do have access to has not given them the information they are looking for. At some level, there is a trust issue involved, and if we use the Edelman Trust Barometer as one piece of data, it is that patients are more likely to trust “someone like me” than their doctor. It’s impressive that we’ve come to this.

Rothman goes on to discuss the virtues of Medline Plus as a place to get authoritative information and “I do not believe that online resources collaboratively created by patients will solve the problems and dangers of healthcare misinformation online.” Again, I think it is the “it is or it isn’t” aspect that we have to be careful of. To Rothman’s comment, I would say, “Is that true 100% of the time?” And I thought about this a bit more as I pulled out a study I have been waiting to read for some time:

Williamson IG, Rumsby K, Benge S, Moore M, Smith PW, Cross M, et al. Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis: A Randomized Controlled Trial [Internet]. JAMA. 2007 Dec 5;298(21):2487-2496.[cited 2008 Mar 13 ]

The study is, I would say, on the incredible side. It challenges one of the most commonly held notions in primary care, that sinus symptoms should result in antibiotic treatment, and shows that prescribing amoxicillin for the most commonly used criteria to diagnose sinusitis was no better than a placebo (sugar pill). I imagine the signficance of this, considering that the average physician may see at least one case of these symptoms each week and the antibiotic cost yearly is $2.4 billion in the U.S. Not to mention that these antibiotics are now in our water supply.

So I next went to Medline Plus, to the Sinusitis topic, to look for the information that says that antibiotics have no effect on the condition in most cases, and that diagnosis itself is questionable.

Sinusitis [Internet]. [cited 2008 Mar 13 ]

No such mention. Is this surprising considering that the average piece of research takes 17 years to find its way into medical practice? I won’t go into why that is here; however, the point is that even the most infallible official resources can be fallible. All that this means is that we should always as “why?” and support our patients asking “why?” also. Of interest, I found out about this peer-reviewed study in the blogosphere, not on PubMed or Medline. We should leave the door open to the idea that patients may just help us reflect on better ways to treat them that are less costly and less harmful to themselves and the environment. It’s a continuous spectrum, not a binary switch.

What about American Medical Association 2001?

I also wanted to comment on Susannah’s use of the press release, which is very important and useful. We have to know where we came from so we can move ahead together. The same year that the press release came out, the American Medical Association also published another piece, “Geraghty K. Historical Postmortem, March 2001 (The Telephone). Jama 2001. (link fixed 03/13/08)” In that piece, my profession’s history with the telephone was discussed - it took 80 years for the telephone to become accepted in modern medicine. But it’s accepted now. And one day, the Internet will be, too. We’re really only 8 years into Internet-enabled health care (using my own organization as the example).

What Susannah presented was what it was: American Medical Association 2001. That’s not the same as American Medical Association 2008. Organizations grow and change. I’m confident that the medical profession will grow and change and use the best tools out there to help our patients. We came from barbers, after all. And I’ve never met a physician that wanted to provide bad health care to their patients.

This post began as discussion of my reacquaintance with the work of theSidney R. Garfield Health Care Innovation Center, which happened when I was in California recently. I was happy to find that they have put up an Internet site for those who want to learn more. I especially recommend looking at the photos. It’s an impressive place - I was able to go on a tour in August, 2007, and I was especially interested in their “mock home.”

What I remembered, though, was that I had wanted to read a landmark publication written by the Center’s namesake, Sidney Garfield, MD, “The Delivery of Medical Care,” which was published in 1970. I believe that learning about where I/we came from as physicians and informaticists is important - the dreams of those who came before us inform our dreams. I was happy see that the article is now available online.

Sadly, the challenges that Dr. Garfield mentioned in 1970 health care ring true today: “In 1967, the National Advisory Commission on Health Manpower reported that medical care in the US is more a colletion of bits and pieces (with overlapping, duplication, great gaps, high costs and wasted effort) than an integrated system in which need and efforts are closely related.”

After reading the piece, I think that his vision is a compelling one today, and much of what he dreamed of has come true today, in certain health systems, such as the ability to administer a health risk appraisal and leverage it as a productive entrance into the health care system (even saying “the entire record is stored by the computer as a health profile for future reference” - this is the name that Group Health has given its health risk appraisal). He understood that poorly informed actors in health care resulted in people entering through the wrong door and

The entry of healthy people into the medical care system should not be considered undesirable. It opens the door to a great opportunity for American medicine: if these well people are guided away from sick car into a new, meaningful health care service, there is hope that we can develop an effective preventive-care program for the future.

There is a heavy reliance on computing power for this new vision, and I might argue perhaps too heavy a reliance; however, what’s remarkable about his models is that they place the patient at the top, with the medical system underneath in support. This is significant, even in 2007.

What’s especially influential for me is his idea that he was a proponent of the Kaiser Permanente model, but was not hoping to make this approach exclusive to Kaiser Permanente. He was open source before anyone knew what that was:

We believe any group of physicians, or a foundation working with physicians, can easily duplicate the Kaiser Permanente success….freedom of choice is important; we believe that the choice of alternate systems, including solo practice, is preferable for both the public and physicians.

I think this is great, and it’s a reason I cite for doing what I’m doing during this experience - helping the entire system succeed in guiding people “away from sick care into a new, meaningful health care service.”

There’s a cautionary note in what I read about over-reliance on technology, and I need to continually check in that I am not promoting technology at the cross purpose of leadership. There is also an energizing note for me about focusing on medical education in this journey - where Sidney talked about the need of medical school faculties to educate about different ways of practice so “these young men can choose wisely.”

The diversity advocate in me appreciates that Sidney Garfield did not predict in his writing in 1970 was that it would be “women and men of all ages and backgrounds” choosing wisely. At the same time, this is a welcome change in our profession that Kaiser Permanente the organization has actively fostered in its work.