While the typical physician is now accepting of the IT changes that are intruding into their work environment, he often does not understand the reasons or the strategic underpinnings for the push for the digitalization of healthcare. Being a typical modern consumer, he understands smartphones, online shopping and email, but doesn’t understand concepts such as clinical data repositories, data warehouses, decision support and business intelligence. Analogies can help, but carts, horses, sticks and carrots are a bit tired.
Being an amateur historian, I realized that the modern military is rife with models that can be used to make the point. These analogies are not meant to be comprehensive of the broad strategic goals of health information technology, but they do help the rank and file physician understand why there is such a push to integrate information technology into the healthcare world.
One example highlights the broad “high level” view in more ways than one. In World War II, the US Air Force generally relied on eyeballs on target to bomb surface targets. Objectives previously were targeted with squadrons of bombers, risking the lives of the pilots and also creating all sorts of collateral damage. It was terror in the air and on the ground. Then in Vietnam, the Air Force began utilizing “smart bombs,” or precision guided munitions. The contrast was illustrated by the Air Force’s campaign against the Thanh Hoa bridge in Vietnam. It was the target of 800 unsuccessful sorties with unguided munitions, but was finally successfully dispatched by a single flight of 12 planes with microchip enhanced bombs.
If you think about how we practice medicine now, we are essentially carpet bombing our patients. This sort of approximated, empiric “targeting” occurs when we treat pneumonias with broad spectrum antibiotics, tumors with chemotherapy, and asthma with steroids and leukotriene inhibitors. These treatments are quite effective, most of the time. Relative to the alternatives, they are also safe, most of the time. However, physicians frequently encounter the “collateral damage” of well-intended treatment such as C. difficile, allergic reactions and drug interactions which are certainly not intended, but occur because we clinicians are constantly barraged by so much data that there is no possible way to avoid all such incidents.
So how do we “smart-bomb” illness and injury? The modern bomber flying at 30,000 feet hitting a small target miles away on the ground does not do this in isolation. It relies on huge amounts of data that is processed by multiple entities from satellites in space to targeting resources on the ground and complex systems within the plane and munitions themselves. We in medicine also rely on large amounts of data that we are required to apply at the point of care. Unfortunately, more often than not, this data is difficult to access (ie. locked as text on paper) and even more difficult to aggregate so that it can be usable and the time and point of care. We need to collect this data, put it together, and use it in real time to affect our clinical decisions. Examples of this are using allergy and medication interaction information to reduce the risks of medication.
However, such information is just the low hanging fruit because medication information is easy to store as discrete data. The vast majority of medical knowledge is locked as unusable data. We need to codify this bulk of clinical data so that is usable by digital systems and patterns can be dredged, enabling our therapies to be more nuanced and accurate.
There are anecdotes describing how Navy destroyers saved the day at the Omaha beach landing on D-Day. The planned landing Omaha Beach on D-Day was a failure. The infantry that had landed on the beach were in chaos and impotently pinned by German firepower in protected positions. However, despite not being part of the plan, these smaller ships were able to move in close to shore and noticed that a lone Sherman tank was pounding in vain against a German gun battery encased in concrete. They were able to provide tactical fire support using their larger 5 inch guns and neutralized the battery.
Noticing this, the tank went on to “target” other batteries and the destroyers apparently were happy to use this information. Despite not having direct communications, resourceful soldiers and sailors cobbled together a makeshift communication system. It didn’t occur to the US military that facilitating tactical communications between the branches (in this case, the Navy and Army) would amplify their effectiveness. Today, the military has embraced the concept of combined arms and integrated systems. Well known example are the AWACS and Aegis combat systems that coordinates various military assets. Such coordination allows military command and control to see data from multiple sources, allowing them to direct their forces efficiently and in a time sensitive manner.
Likewise, our healthcare environment is currently a victim of information isolation. It is quite common to have patient information from separate sources inaccessible to the providers who are actively taking care of a patient. A patient can be hospitalized with much of his data locked in a doctor’s office or vice versa. Obstructions to information flow can even occur in the same physical plant. It is quite common for doctors, nurses, and other ancillary providers to record and document information in different ways and on separate parts of the chart or even separate physical charts. Because of this, it is even common for the patient to go through their inpatient clinical course without doctors even looking at any nursing documentation. The eventual goal is a single common electronic patient document. The patient information then is simultaneously available to all providers as a single merged source of truth, allowing a coordinated approach to the care of the patient rather than multiple strategies that are blinded to other practitioners.
The US military uses Special Forces teams (typically 12 men) to train a larger size (100-200) of indigenous fighters to engage in guerrilla warfare. Thus, the Special Force unit has multiplied their effective size. The GPS technology we now take for granted in our cars allowed the US led coalition forces to outmaneuver the Iraqi forces in the first Gulf War, allowing the Allied forces to choose when and where they wanted to fight, again, making a fighting force more potent than their pure numbers. These tactics and technology were force multipliers, amplifying the strength of a single unit or soldier.
We often hear about the silos of data and information in health care. However, we also have silos of knowledge. It took 15 years for 50% of patients to receive beta-blockers after myocardial infarction and 25 years to reach 90%. The studies and knowledge that beta-blockers improved outcomes was readily available, but the academics failed to reach the trenches of real world medicine. If this clinical knowledge had been presented at the appropriate times, compliance would have reached 90+% much sooner. Reading about evidence based recommendations and filing them away is one thing.
Trying to remember and implement them during the chaos of the real world medicine is more difficult. Decision support allows such recommendations and reminders to be delivered at the point of care, where we wage the real fight. Discovering evidence based practices is not enough. We must use technology enhanced decision support to amplify and accelerate evidence based academic findings when and where the clinician needs them, not locked up in a journal.
Our healthcare environment and national economic circumstances dictate that we take care of patients better with fewer resources. Although it may seem odd to relate strategies used by an organization to exert physical power to the healing purposes of healthcare, the US military has evolved its technology and tactics to be a leaner but more potent force. Healthcare can learn from their evolution to be leaner and more potent as well.
John Lee is an emergency physician.