On 14/03/2018 10:28, Philippe Ameline wrote:
Bert,
The main reason I mentioned the [Troll] hashtag was because I am
really conscious that what I say is far from being mainstream. Hence I
consider myself honored that some of the things I say can "rock the
boat" a little bit and raise several questions.
To tell it roughly, I consider that practitioners are missing two
crucial turns: they are disconnected from the information society (for
several reasons, medical confidentiality of course, but also because
MD keep seeing information systems as "back office" components, also
because they are often individualists very at ease in silos (practice
and specialty)) and they are still fully organized for acute care (to
put it simply, the medical system is fully upside down and the GP
should become an orchestra conductor (what she often dreams she
already is) but is stuck in the one-man band role).
that is exactly right, and I think there is still a revolution that must
come to get the GP out of the solo 'cabinet mental' and indeed be some
sort of a) team player at the practice level and b) orchestrator of care
- in terms of managing referrals and the outcomes, post-care etc. But
that is not our business, the healthcare profession needs to work this
one out.
It could make sense to consider that the first lock (the dead branch
of the information society flow) controls the second lock (missing the
chronic care turn). This for many reasons:
- chronic care means managing risk over a long span of time,
- chronic care means genuine team work around a given person (not the
fixed team "inside the same box" but the dynamic team of the
contributors around a given individual).
Translated in technological concepts, my own take is that is means
switching:
- from a record oriented vision to a project management vision (a
record is the place where you optimize your own decision support
ability through keeping the signal/noise ratio as high as possible ; a
project manager is the place where people build/feed/contribute to a
set of shared processes).
I don't quite agree here: because the 'record' (properly conceived) is
the only thing that exists to chart the long-term situation of the
patient, as doctors retire, nurses go on holidays, patients themselves
move to new cities or countries. What can you trust to tell the story
from your childhood asthma to your 2 pregnancies and births, to your
hypertension and type 2 diabetes? Or even just your 10 year battle with
one of the lesser cancers (very common) or lifelong management of a
single disease. There is only the longitudinal health record.
I agree though with the project management notion of course. Our recent
work on Task Planning
<https://www.openehr.org/releases/PROC/latest/docs/task_planning/task_planning.html>is
trying to get up to this next level and join 'model' care pathways with
real patient care plans and team-based care processes. It's going to
take some years to get it really sorted out, but I think we are on the
right path. I have seen the latest increment of the Activity-Based
Design work at Intermountain Healthcare last week - we are converging.
So when I say the 'EHR' I also include informational artefacts from
long-running Planning and work processes, not just what we have today,
which is observations, decisions, orders, and a record of actions done.
- from a "care places centered" system (the patient moves from silo to
silo, from record to record) to a system "federated by the person"
environment. To put it simply, it is a genuine Copernican revolution
where individual, instead of having siloed information stored about
themselves in every "box" they cross, would own a system in support of
their life long holistic vision and ask their services providers to
contribute to it (means to join a team).
I think this revolution is starting. Now it is becoming clearer to the
industry what has been obvious to us - that no single provider creates
all the data that relate to the patient, so the long term solution is
healthcare data and major services (workflow / process) must eventually
be part of a back-end system that isn't owned by any product vendor or
care delivery location, but instead managed on behalf of the patient by
a trusted third party.
A colleague many of you will know, Amnon Shvo, from Haifa, has been
going on about the 'EHR Bank' for at least a decade now. I remember
saying to him 10 or 12 years ago, this is the right idea, but the
industry won't accept it. But now I think it's becoming clear that the
industry is going to have to accept it, and those vendors who don't want
to will be relegated to the outer reaches.
The most important point to consider here is that, when considering
the person's bubble, it is really mandatory to be plainly holistic,
that's to say to consider health as a project among many other
projects (education, employment, social issues, ordinary life
projects, etc). It is a place where the term "patient" is prohibited.
I would say: the term 'patient' just gets demoted to meaning a
client/supplier relationship that sporadically occurs between a person
in a health system, and the health system's healthcare provider
organisations.
- thomas
--
Thomas Beale
Principal, Ars Semantica <http://www.arssemantica.com>
Consultant, ABD Team, Intermountain Healthcare
<https://intermountainhealthcare.org/>
Management Board, Specifications Program Lead, openEHR Foundation
<http://www.openehr.org>
Chartered IT Professional Fellow, BCS, British Computer Society
<http://www.bcs.org/category/6044>
Health IT blog <http://wolandscat.net/> | Culture blog
<http://wolandsothercat.net/>
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