Wednesday, June 29, 2011

Supercourse: Epidemiology, the Internet and Global Health

Here is the description of "Supercourse" from the home page at the following URL.

http://www.pitt.edu/~super1/

"Supercourse is a repository of lectures on global health and prevention designed to improve the teaching of prevention. Supercourse has a network of over 56000 scientists in 174 countries who are sharing for free a library of 4855 lectures in 31 languages. The Supercourse has been produced at the WHO Collaborating Center University of Pittsburgh, with core developers Ronald LaPorte, Ph.D., Faina Linkov, Ph.D., Mita Lovalekar, M.D., Ph.D. and Eugene Shubnikov M.D.. Please contact us at super1@pitt.edu"

Sunday, June 26, 2011

First Reflections on the 2011 AUPHA Conference

I just returned from the AUPHA Conference in Charleston. Reflecting upon the sessions and the conversations I am struck by the strength of commitment to prepare graduate students to effectively manage the dramatic changes taking place in healthcare today. These women and men, living in the "publish or perish" world of higher education and the "politics" within universities, have real commitments to their students and to helping less-experienced scholars entering the field become effective teachers. There is a deep awareness that the quality of classroom teaching literally means the life or death of future patients and the success or failure of healthcare organizations.

Saturday, June 18, 2011

Clarification of Care Pathways and related terms?

It is Saturday evening and I am trying to sort out in my mind a set of related concepts that appear to be near the heart of how ACOs will hopefully help reduce costs and improve outcomes. It appears that a number of terms (clinical pathways, care pathways, integrated care pathways and care maps) are all used more or less interchangably. If so, there appears to be a need to sort out these terms and to use them more precisely. I think a "clinical pathway" refers to an evidence-based approach to addressing one patient's one specific apparent need. But, what of the needs of a patient with multiple medical conditions? And what of the need to do aspects of planning that are not clinical in nature, such as discharge planning and financial planning? The idea to rationalize care in a larger context than is possible with our presently fragmented ecology of providers.

Elderly patients are likely to have multiple chronic conditions. Does "integrated care pathway" mean a customized clinical pathway that includes one patient's multiple conditions? Will there be computer applications such that one patient's mutliple conditions are input and the computer produces an integrated clinical pathway that seeks collapse multiple parallel pathways into one sequence of events for that specific patient? There are complex relationships among the many subsystems of the human body and individual differences among patients with similar combinations of conditions. Any attempt to optimize the way care is provided as related to multiple medical subsystems is going to require monitoring and real-time adjustment.

I am presently reading a book titled, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering by Hollnagel and Woods. The book is about cognitive networks that include both artificial and natural intelligence. When humans attempt to control a complex system they must be able to anticipate the "behaviors" of the various "agents" within the system. When some of the agents are computer programs that include artificial intelligence the ability to anticipate the behaviors of those agents can be difficult or impossible. Intelligence (artificial or natural) produces emergent behaviors, especially if the computer programming includes some generation of probability distributions, as when simulation software is used to control real systems. Not even computer programmers can fully anticipate emergent behavior and as a result "bugs" are sometimes defined to be unanticipated "features" of the software.

My conclusion at the moment is that we need to clarify terms like, "care pathway" so as to be more explicit regarding how ACOs are going to constrain costs and improve outcomes. The political case against the recent health care reform legislation was expressed as "bureaucrats" standing between physicians and patients. It seems to me that another aspect of concern is the prospective substitution of joint cognitive systems for the professional discretion of individual physicians. Is the phrase, "evidence-based" serving to help us feel more comfortable with a shifting from natural intelligence to artificial intelligence as we prepare to scale up our nation's healthcare delivery system? And how can accountability be assigned when care implementation is defined by joint cognitive systems including artificial intelligence? If the entire system is sufficiently complex, no part of it can be held responsible for adverse system outcomes.

Friday, June 17, 2011

Seeing Patterns in Data, Taking Actions in Life

As a university teacher I have taught on an number of campuses during my career. A few students remain in mind through the years for either having made a lasting positive impression or a lasting negative impression. I remember one student in a previous university employment who told me that as a public official her preparation for the prospect of a deadly epidemic would be to buy lots of coffins. I was at the time trying to teach her and other graduate students to use computer modeling to gain insights into dynamic complex systems so as to be able to take informed preemptive actions. In retrospect I realize that I should have been better prepared to demonstrate use of the software to my graduate students. But neither my colleagues nor my students seemed to appreciate the pedagogical use of computer simulations to help students better understand complex systems. I think now that if I had only shown students a computer simulation rather than asking them to think through the modeling of one the assignment would have been deemed acceptable. I have for years advocated that the academic field of public administration become more of a design science with ties not only to political science, management and business administration, but also to operations research. I take some comfort in the thought that Herbert Simon, if he were still with us and if he knew, would approve of my efforts, even if my efforts have on occasion contributed to the mobility of my career.

These memories were sparked this evening upon viewing the following TEDMED 2010 presentation. Jay Walker spoke of the origins of public health statistics using a Bills of Mortality book prepared during London's great plague of 1665. To me, his point is that data is the necessary basis of information that can support the knowledge needed to recognize patterns and design interventions.

If you would like to view the video directly from the YouTube site the URL is as follows.

http://www.youtube.com/watch?v=5IRsqDnPzSE

Tuesday, June 14, 2011

Tradeoff between quality of care and readiness to practice?

The following CNN Health report includes a CNN Radio report regarding new regulations limiting the lengths of shifts worked by medical interns and residents.

http://thechart.blogs.cnn.com/2011/06/14/limiting-student-doctors-hours-cuts-both-ways/?hpt=hp_bn6

The essential point is that while long shifts have been shown to contribute to medical errors that "shorter" shifts (say 16 hours at a time) will undermine the quality of the educational preparation of medical interns and residents. In a comment to the report "ramparts1815" stated that recent graduates know less and can do less than graduates five years ago. He or she adds, "And the public should realize that really good doctors and surgeons peak at 5-10 years after training."

As a university teacher I think a lot about the level of preparedness of new graduates. Something seems to be happening that is affecting the nature of the cognitive skills of emerging young professionals. Perhaps it is the cognitive overload of trying to digest so many streams of incoming information at a time. Even watching CNN television now involves continually receiving two or three news reports at the same time. Nicholas Carr suggests as much in his book, The Shallows: What the Internet is Doing to our Brains. It has been suggested that increasing rates of autism may be of environmental/chemical origin. If true, might the same chemicals be affecting the cognitive capacities/processes of all of us? Are we each losing individual cognitive capacity while our networked collective capacities are increasing?

To me, the bottom line is that if it takes increasingly long to educate physicians and surgeons and if their abilities peak and then tend to decline only five to ten years after graduation, we have problem. All things considered, if I have to be rushed into a hospital for some medical emergency I hope to be seen by people who are not so tired they cannot at that moment provide their wakeful attention. Nor do I expect when I go to a physician that others have perhaps endured medical errors in the past so as to somehow contribute to the quality of his or her education. I don't claim to have the answers here, but I wonder if there is something incorrect in the reported concern that when someone in training goes home for rest after a 16 hour shift that they do not adequately appreciate their needs to learn.

Sunday, June 12, 2011

Scope of a Miracle

It is good to see photographs of U.S. Rep. Gabrielle Giffords that became available to the public today. Few people know all the details of the kinds of care she received that made possible the near miracle of her survival and recovery. There are surely many physicians, surgeons, nurses and others who together made this possible. She is alive and recovering today because of the coordination of the efforts of many professionals. In other words, it was not only the skills of individuals who saved her life and promoted her recovery. It was the timely coordination of those efforts. In this case, the "system" of care worked. I want to believe it would have worked as well for any person who suffered her injury.

As I read some of the comments received by HHS regarding proposed rules for implementation of ACOs I see the strong expressions of good people who simply do not want government agencies to attempt to rationalize the healthcare delivery system. Some people are simply opposed to "socialized medicine" and/or define the proposed changes as a loss of freedoms won on battlefields around the world. Others are open to change but do not believe that the new law and the proposed rules will work. Rep. Giffords' recent experiences with the system could be cited either as evidence that what we already have can work; or to say that we can do better. I want to believe that we can do better for at least all American citizens, including the large numbers of people entering the Medicare program. I believe that the rationalization of medical processes can reduce costs and produce more consistent quality outcomes for all patients.

It is a safe guess to say that the implementation of the new law will produce unintended behaviors among providers. The system that produced the law is a political system. Democratic political systems cannot produce scientifically rational policy designs, as in the context of operations research which is rational in a more objective way. Politics is the art of what is politically possible. As we pray and hope for Rep. Giffords' continued recovery let us continue to hope that the new law which she supported in Congress with her vote backed by her courage can be implemented successfully. "Bureaucrats" have to run with what they are handed by others.