J. Peter Melrose, owner and CEO of healthcare provider IT consulting company CHARTSaaS, in Fort Mill, S.C., discusses the potential of mobile applications, created in do-it-yourself mode by healthcare providers, and how this approach can improve physician performance and patient safety.
Responses have been lightly edited for clarity and length.
Question: Where do you see the biggest need for innovation to improve the healthcare system in the future?
Peter Melrose: The biggest need is at its core: transform the practice of medicine and delivery of healthcare by equipping professional, typically physician, and organizational, typically hospital, healthcare provider subject matter experts with real-time and customized cognitive support. This is because cognitive overload arguably is the root cause of medical mistakes, which currently are the third leading cause of preventable patient deaths, numbering between 220,000 and 440,000 annually in the U.S. alone. It is also because of cognitive limitations, traditionally and tacitly denied by doctors because of their education based on medical process and patient data memorization; this approach continues to reinforce the tendency toward eminence- rather than evidence-based medicine.
Larry Weed, MD, the inventor of the problem-oriented medical record and a health IT mentor of mine, elaborated on physician clinical cognitive limitations in his 2013 tome co-authored with his son, Medicine in Denial, as summarized in its overview thus:
'Essential to healthcare reform are two elements: standards of care for managing clinical information (which is analogous to accounting standards for managing financial information) and electronic tools designed to implement those standards. Both elements are external to the physician's mind. Although in large part already developed, these elements are virtually absent from healthcare. Without these elements, the physician continues to be relied upon as a repository of knowledge and a vehicle for information processing. The resulting disorder blocks health IT from realizing its enormous potential and deprives healthcare reform of an essential foundation.'
Q: What advice would you offer to hospital executives looking to improve physician happiness when it comes to the EHR?
PM: Hospital executives must appreciate that EHR systems are what IT professionals refer to as 'systems of record,' the purpose of which is to facilitate the revenue management cycle by managing patient administrative and clinical data to facilitate billing and maximize revenue. Therefore, to improve physician happiness and more importantly to improve practice efficiency and effectiveness, and thereby to improve patient safety and to optimize case outcomes, hospital executives must implement 'systems of engagement' typified currently as IT mobile applications or ‘apps.’ Apps can provide the real-time functionality that healthcare provider subject matter experts require for practice and delivery improvement by leveraging the EHR patient data in real time with typical app features such as mobility, ease-of-use and multi-modal capabilities like photography and global positioning.
Therefore, hospital and other healthcare provider organization executives should implement the Cloud Healthcare Appliance Real-Time Solution as a Service (CHARTSaaS) reference architecture; using a commercial off the shelf and/or a free open-source low or no-code mobile app development platform software solution, as currently used in other industries worldwide; and deployed behind a secure portal in the Internet cloud for maximum security, accessibility, reliability and cost-benefit — no capital costs, long-term contracts or IT resource impact.
Q: What is the most exciting thing happening in health IT right now? And what is the most overrated health IT trend?
PM: The most exciting thing happening in health IT these days is the far-too-gradual recognition of IT-enabled cognitive support in the form of apps as the solution to the clinical cognitive overload problem, and thereby mitigating medical mistakes and saving patient lives. The SafeDose Mobile app for pediatric medication dosing invented by James Broselow, MD, an American pediatrician and emergency medicine physician, demonstrates the wide variety of available capabilities leveraging Internet cloud platforms and mobile phone features such as barcode reading, voice recording and photography. Hundreds of other use case-specific apps and independent software vendors' services are available currently via the Internet for custom app development or licensing and downloading.
However, the associated costs and complexity of acquiring and administering these apps, coupled with the technical and administrative challenges associated with EHR system interfacing, can be prohibitive for general use. Even more problematic is the fact that healthcare providers are either unwilling or unable to appreciate and adopt mobile apps; because of their traditional support of eminence-based, as opposed to evidence-based, medicine that arguably is cultivated by conventional medical education, and also their significant cost and cultural investment in the functionally inflexible IT second-generation EHR systems that saturate the provider market space.
The most overrated health IT trend currently is toward greater use of artificial intelligence, which, perhaps because it is in fact a misnomer — the intelligence is genuine — and/or the 'black box' nature of its outputs and/or the intellectual difficulties posed by its Bayesian multivariate statistical tools and methods, yields suspect or misunderstood results that at best may lead to contractual issues and at worst may jeopardize patient safety because of cognitive-based medical mistakes. Of course, human cognition can and must benefit from IT support to effect Dr. Weed's vision of healthcare reform; but this support must be provided in a transparent way and in context of medical practitioner understanding and clinical pathway and process operation.
Q: CHARTSaaS focuses on enabling healthcare providers to create their own information technology apps with low cost and complexity. Can you describe some of the specific problems these IT apps help providers tackle?
PM: Among the virtually infinite number of cognitively intense use case candidates for cognitive support apps that CHARTSaaS could automate in the hands of healthcare provider subject matter experts without IT expertise, most include one of the following four persistent sub-processes that recur frequently in medical practice and healthcare delivery and pose high patient morbidity/mortality risk:
Failure to rescue —preventable patient death owing to a clinical complication not recognized in a timely manner or treated appropriately; avoidable using an app for sepsis/systemic inflammatory response syndrome management
Constant monitoring — observation of patient, disease, condition or other sentinel medical parameters continuously over time; essential for a Type 2 diabetes management app
Alarm/alert fatigue — desensitization to device-generated alarms/alerts, typically by bedside monitors, owing to high number/frequency; avoidable using a low-latency data stream analysis app with staff notification conditional on predefined device-specific parameter thresholds
Hand-off communication — complete, accurate and timely transmission of patient-specific care/treatment information from one healthcare professional to another; achievable using an app to monitor patient EHR data fields with preformatted display on request and automatic notification of missed scheduled events or problematic order/observation updates
These pervasive use cases are excellent CHARTSaaS mobile app candidates because they rely on functionality that only cloud-based IT can provide reliably as scheduled 24/7 without error
Q: How can CHARTSaaS help increase physician satisfaction and workflow?
PM: The CHARTSaaS reference architecture specifies an app management software toolkit designed for healthcare provider subject matter experts without IT expertise but only drag-and-drop, point-and-click and keyboarding techniques to design, develop, deploy, operate and optimize automated processes. In this way, the impediment to healthcare reform described by Dr. Weed can be overcome: '... the physician continues to be relied upon as a repository of knowledge and a vehicle for information processing. The resulting disorder blocks health information technology from realizing its enormous potential.'
Subject matter experts will be able to create and operate digital and automated artifacts such as decision tables, complex event conditional monitoring and continuously operating or on-demand processes easily; and they will be able to modify these processes collaboratively, with other subject matter experts and/or patients and their responsible parties and caregivers. Therefore, they all will be active participants in medical mistake mitigation, case outcome optimization, acceleration of medical knowledge accrual, access and application globally.
To learn more about CHARTSaaS, click here.
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