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IT, Networks and Medical Care

General issues:

This unusually long and detailed article compiled from my summers experience surveys what I believe to be the most up to date and most critical issues of the application of computers and information technology networks to healthcare. I point out that it is a system without a roadmap and without any recognized rules of auditing and accountability and I use my own experience over the last decade with spinal osteoarthritis and degenerative osteoarthritis of my hip joints to point out the risks and medical wastage of navigating within the current system.

The first application of information technology that I ever wrote about was more than 30 years ago with Dr. Larry Weed’s Problem Oriented Medical Information System. As I look back I can see now how this was the first instance of what has for me become a career in identifying revolutionary technologies and trying to connect them to a larger marketplace and into  broader knowledge.

I have been able to reconnect with Dr. Weed and also with the current director of customer relations for the PKC Corporation which Dr. Weed founded in 1982.  Before I started I knew only that Larry Weed’s revolutionary ideas have not yet been adopted.   I found out however that they have gone much further than I realized. I have spent many hours this summer delving into his knowledge coupler concept. I have found that I like it very much and wish him all success. I have also experienced - with a left hip replacement this summer  - the current resistance of these very good specialists to becoming patient-centered rather than provider centric. There is a long long way to go. I show this in the chapter devoted to my personal health history.

The most critical issue however is that the predominant direction of the healthcare debate other than the political ideologies upon which it is foundering is to as Larry Weed says speed up the chaos by applying networks and computerized records to diverse systems that cannot communicate with each other that are not logical in the sense of them being auditable across providers and, as Larry's son Chris wrote nearly 20 years ago, is that while the purpose of medical research is to discover new knowledge, the purpose of a medical practitioner is to apply existing knowledge to the problems of the patients who come to this practice. In keeping with his premise, Larry has developed a rigorous system for linking this combination of medical records according to the problem to which they relate rather than to the source from which they come and then to a rigorous computerized database that takes a listing of patient problems and clinical observations and tests and couples it in a rigorous way according to the patient's health history to existing medical knowledge producing guidance for the physician that far exceeds the capability of the human brain.

I close this long investigation with a summary of a new approach that is just beginning to be discussed.   It is the concept of the patient centered medical home.  IBM has produced quite an outstanding white paper from which I quote.  From the research that I've been able to do it seems that this concept may be embraced by insurance companies and come out of this round of healthcare reform to replace the health maintenance organization concept that was the product of the last round of reforms in 1994.

This new approach is oriented to the Internet, to web-based interfaces for health records, to active patient involvement and electronic communication with their physicians and with indeed all members of the healthcare team.  I find it very very attractive especially considering how it could have made my experience with my second hip replacement this summer much smoother and less fraught with risk.

Although it does not yet use the knowledge coupler  concept or problem oriented medical records, in my opinion it does embrace virtually everything else that would come to mean a positive direction for serious changes in healthcare. By this I do not mean insurance. That is a monetary and political issue and well outside my present capability of writing about. And while the COOK Report has discussed such concepts as telemedicine, as usual in this case human interface factors are critical.  High-speed optical networks do absolutely no good if the patient is willing to use them to transmit visual or other data about his condition while his physicians on the receiving end of the line are unwilling to participate.

This is a fundamental matter of paradigm change in the very structure of Thomas Kuhn's masterpiece of four decades ago The Structure of Scientific Revolutions. I am hopeful that given the strains and perturbations of the old system failing to meet so many needs that the new system may begin to make serious progress.  Such progress would be a given if medical schools could be encouraged or yes even coerced into changing their four centuries old ways of medical education. Although there are many disparate strands of health care issues, if I can make a contribution with what I have pulled together it would be to bring greater recognition to Dr. Weed’s logical and defensible system for rigorously connecting the day-to-day practitioner with medical knowledge in such a way that many fewer mistakes will be made and the inaudible chaos and consequent expense removed from current medical practice.

An Outline of Dr. Weed’s Basic Critique


While medical research is founded on a firm scientific basis. .  .

Medical practice founded on the provider’s memory and intuition – it is hit and mis with no feedback loops – it may qualify as art but is definitely not science.

Because practice exits without acceptable standards for record keeping and decision making medicine  exists and operates in chaos.

It is a fragmented and rushed system where patients are prevented from making the decisions about their own care that would be possible if they had access to relevant information.

Under these conditions, coordination, feedback, learning and problem management plans tailored to the unique differences among patients are impossible. They are impossible because there are no established rules, no uniform standards that can permit the compilation of data to measure outcomes.

Without such a uniform framework, patients cannot manage their own care and take advantage of access to information brought about by computers and the internet.

In short “A trustworthy and transparent intellectual infrastructure for care”  does not exist.

Such an infrastructure depends on two tools being available to physicians and patients
The first is a map of the landscape – that is a compilation of medical knowledge that is relevant to patient by being filtered and focused on his problems.

The second is a communication system between patient and care givers for navigating the journey – this communication system must consist of well structured medical records that uniformly map the steps taken by patient and care givers as they cross the medical landscape.

Decision making should begin within a uniform framework of rules standards and knowledge, and be mapped by patient and caregiver according to the nearly infinite variety of journeys that can be taken across the medical landscape of patient differences and needs.

The patient should not be subject to the chaos of haphazard decision making the outcomes of which are gathered into a grand study of what works and what doesn’t and that is used to force every other patient into the same procrustean bed regardless of what condition, risk factors and history the patient brings to the table.

There are two problems in managing information:
first - general knowledge must be applied to patient problem specific data.
second - the data generated by patient provider interactions must be systematically organized over time.

To couple general knowledge with specific patient problems. This can be done with the linkage of computer software that given the patients medical history and presenting conditions matches that information against the universe of medical knowledge relevant to the problem and extracts linkages between the two – giving the physician and patient some scientifically verifiable evidence of the soundness of a course of proposed treatment

The coupler system uses a standardized treatment framework to capture the patient history and maintain that over time so that patient and caregivers alike are operating off the same playbooks.

To progress these problems can be dealt with at two levels.

1. reform of the entire system of medical education
2 -use of the problem knowledge coupler system integrated with the computerized problem oriented medical record in the hands of patients and providers  designed as a means of dealing with the shortcomings above."


Symposium Discussion

CRTC and Understanding Network Bandwidth p. 65


McCollough: The Wikipedia explanation Eric provides makes this clear - that we are looking at peak, not consumption over a month:

"Burstable billing is a method of measuring bandwidth based on peak utilization. It also allows usage to exceed a specified threshold for brief periods of time without the financial penalty of purchasing a higher Committed Information Rate (CIR, "commitment") from an Internet service provider (ISP)."

Feld: See, nobody at the FCC or in policy land knows this [stuff.] Not because we don't care, but because no one who actually knows this [stuff] bothers to talk about it. Then y'all get pissed at how ignorant the people making policy are.

Broadband Stimulus What Difference p. 67

Savage: Have you given much thought, yet, to the gritty, pragmatic question of applying behavioral economic insights to regulation? For example (to randomly throw something out), one of the points that Thaler & Sunstein make in Nudge is the importance of default choices. Today the FCC initiated an NOI about the wireless industry. I wonder if, retail competition etc. notwithstanding, behavioral economic considerations would justify the FCC in specifying certain default terms in wireless consumer contracts, with various nontrivial requirements imposed on carriers seeking to get a consumer to select a contract term that is different from the default.  [snip}

Savage: Behavioral economics hits the Chicago School where it matters. It shows that people don't in fact make decisions "in their own best interest," which is required for the basic neoclassical model to make prescriptions, i.e., for them to say that the result of an unfettered market is the "best" achievable in some sense. Macro stuff like Keynesianism and Marxism doesn't quite get there, IMHO.

Kushnick: I don't know about schools of economics. Kushnick's law is based on predictable behavior of both the phone companies and the regulators - the idea that free markets exist and they work is pure poppycock. It is based on trajectories of behaviors - and it can be different for different companies within a segment, but..

Open Networks and CLECS Good Idea? p. 72

Cooper: What you need is a business model, a governance model and a security model.

COOK Report: agreed Mark... ya got one for us?

Cooper: Who is the us and what do they want to accomplish? The government is bankrupt, the Congress is paralyzed and the FCC is in a coma. I spent more time trying to make the unbundling regime work than just about anyone, but its gone and it ain't comin' back; ditto with muni-broadband.

So, which are the most important piece parts of the current terrain that can be tweaked to make things better. Special Access, universal service fund reform, a little more unlicensed spectrum, preserving network neutrality as we now have it?

In the alternative, you can wait for "We the people" outside of Washington to rise up and elect a genuinely progressive government that will revolutionize the communications space.

IPv6 Transition  p. 78

van der Berg: RIPE NCC is doing a lot to promote IPv6. You might want to have a look at the contents of their Roundtables here.
http://www.ripe.net/meetings/roundtable/feb2009/presentations/ Next week there is another roundtable here in Amsterdam

Tom Vest (external consultant, RIPE NCC / Science Group) :  Other resources that you may find useful:

http://www.ipv6actnow.org/

-- especially: http://www.ipv6actnow.org/category/all-news/government/

http://www.getipv6.info/index.php/Main_Page

The OECD has also made some efforts along these lines, c.f.:

http://arstechnica.com/old/content/2008/05/oecd-notes-ipv4-depletion-nudges-governments-towards-ipv6.ars


 

Contents

Health Care, Internet and IT at a Crossroads

Can Economic Stress Drive the Evolution of a New Patient Centered Medical and IT Networked Paradigm?

Introduction                                         p. 1
What Has Happened Since 1979?                          p. 3

Chapter One     E-health” as Part of a National Broadband Strategy

Some Thoughts from Australia                            p. 5

Chapter  Two  Larry Weed’s Critique of Knowledge Based Medical Delivery                        p. 7

A Final Question                                    p. 8

Chapter Three
Risks:  A Personal Odyssey -- Ten Years of Navigating the System

February 2000 Laminectomy                                  p. 10

March 2000 Cervical Discectomy,                                 p. 10

Hospital, Insurer and State Medical Board Reaction – “Tough”     p. 13

Their Spinal Trained Eyes Were not Much Use in Tracking the Joint Source of the Pain                               p. 14

Swelling in 2006 and Difficult Travel in 2009                      p. 15

No Post-operative Plan                                        p. 17

Chapter  Four

A Summary of Larry Weed’s Indictment of the Current System and His Work to Correct It

No trustworthy infrastructure for the Delivery of Care            p. 21
Couplers Conceived By Larry in 1978 and PKC Corp. Formed in 1982                                                  p. 23

Chapter Five  The Problem Knowledge Coupler Corporation -- How the Couplers Work, DOD and Electronic Medical Records

An interview with Dave Southwick                            p. 26
How Couplers Are Used                                         p.27
Linking Couplers with One’s Google Health Record            p. 28
DOD and AHLTA                                            p.29
On Going DOD Work                                          p.31
Electronic Medical Records  Communication and Use,         p.33
Couplers as a Means of Establishing Acceptable
Standards of Care                                            p. 35
Need to Move Data Between Electronic Systems,                 p. 36
Where Are We Headed?                                        p. 39
Appendix: Coupler Text                                p. 41
Joints, Bones, and Muscles                                    p. 42
Low Back Pain Diagnosis Coupler                             p. 43

Chapter Six  What May be Possible in the Near Term:  The Patient Centered Medical Home Form of Group Practice

What is the Patient Centered Medical Home?                     p. 48
A KEY TO CHANGE: ELECTRONIC RECORDS                   p. 52

Postscript 1979 Futurist

Rx For the Maladies of Health Care: A Medical Revolution in the Making

The Prpoblem Oriented Procedure                                p. 54
Medical Costs and the POMR                                    p. 58
Medical Education and the POMR                                  p. 59


Symposium Discussion August 17 - September 18, 2009

CRTC Protects Bell Canada from ISP Competition                          p. 65

Broadband Stimulus What Difference?                                          p. 67

Are CLECs and Open Networks a Good idea?         p. 73


IPv6 Transition                              p.78

Executive Summary       p. 84