Data, Information, Knowledge, and Wisdom

One of the challenges of being a doctor in the 21st century is information overload. More medical literature is published every year than a doctor can read in a lifetime. As electronic health records become more common, doctors can be overwhelmed with data gathered about each patient. Doctors do not want to review hundreds of normal findings, they want to know what is actionable for each of their patients to keep them healthy

Healthcare CIOs should implement applications which filter data so that it becomes information, transform information into knowledge, and ulimately provide clinicians with wisdom based on that knowledge at the exact time they need it.

Here's an example. Suppose a patient's blood pressure is 100/50. That's data. Suppose that patient has a ten year history of blood pressures of 150/100. That's information. Suppose that the patient has a known history of coronary artery disease and is now experiencing chest pain. The sudden drop in blood pressure could indicate a serious myocardial infarction in progress. That's knowledge. It's time to give the patient an aspirin, oxygen, and nitrates immediately. That's wisdom.

Recently, I asked my primary care physician to export my entire history from his electronic medical record system. Although I'm a completely healthy person, the result was a 77 page PDF. The document contains a mix of administrative and clinical data, numeric observations and unstructured text. It would take a physician about an hour to navigate all this data.

How can we turn this data into information? Over the past few years, my clinical information systems team, led by Dr. Larry Markson, has built "event driven medicine" into our applications. Events such as changes in medications, patient visits for diagnostic testing, lab results, or newly discovered allergic reactions generate data which can be transformed into actionable wisdom. Here are three examples:

When a doctor writes for a medication at BIDMC, a query is sent to our regional data exchange determining the patient's insurance coverage for pharmaceuticals. Based on the answer, we access the appropriate payer-specific formulary so that all medications are preferentially chosen to minimize cost and maximize effectiveness for each patient. Every prescribed medication is checked against the entire history of the patient's active medications from pharmacy and payer databases throughout the country. Safety issues, guidelines and best practices are displayed to the clinician, ensuring quality care. When the correct, safe medication in the right dose is selected it is instantly routed to the pharmacy of the patient's choice, going from the doctor's brain to the patient's vein without any handwriting or human interpretation. All of this happens in real time based on the data found in electronic health records, information about trends in body functions, knowledge from decision support databases, and wisdom from the orchestration of all these moving parts behind the scenes via interoperable web services, ultimately providing the best choice for each medication written. This week, we just completed our 100,000th medication processed this way.

When a doctor orders a radiology test a BIDMC, a query is sent to a decision support engine which we co-developed with Safe-Med. Over 1000 best practice rules from the American College of Radiology and the world's radiology literature are examined, along with patient medications, laboratories, allergies and demographics, to select the most appropriate radiology test based on evidence. Radiology exams are scored from 5 stars to 1 star (the image shown above), balancing efficacy, risk and cost. If a clinician orders one of these tests, a pre-authorization is sent to the payer in real time and the test is automatically approved. All of this happens in a few seconds, using patient data plus the knowledge from the literature to yield a wise choice for radiology diagnostic testing. 100% of high cost radiology tests are processed this way.

When a doctor identifies a chronic diease condition at BIDMC, a decision support "screening sheet" is created to track all the events in a patient's care. Diabetic tracking includes lipids, glucose, eye exams, foot exams, Hemoglobin A1-C, immunizations, and weight. Whenever an event occurs - such as a lab result or appointment, the screening sheet is updated and decision support rules recommend the best practices for diabetic care, filtering all this data into a concrete set of recommendations such as "patient is past due for an eye exam" or "patient should receive pneumovax this season". Clinicians do not need to focus on the raw data, instead they can review suggestions in real time to optimize the care of the patient. This year we achieved all our pay for performance goals using this approach.

Like many other projects, the pursuit of event driven medicine is a journey. Over the next few years, we'll continue our efforts to ensure that clinicians are given the real time wisdom they need to deliver safe, cost effective and appropriate care.