Hesse hopkins 2014

“Deep Support” in Patient Care
Reengineering Healthcare to Support Patient-Centered
Communication and Continuity of Care
Bradford W. Hesse, PhD
Chief, Health Communication
& Informatics Research
Wednesday, June 18, 14

A Lonely Road*
Limited Support
Cloistered
knowledge
Struggle with
adherence
Silo’ed &
inaccessible
records
Fragmented care
Doctor centric
medicine
* Hoffman, Jan. (2005,August 14, 2005).Awash in Information, Patients Face a Lonely, Uncertain Road, NewYork Times.

“Greatest innovators (e.g., Henry
Ford) ... discovered the possibility
of a new kind of convergence
between consumers’ desires,
technological capabilities, and
organizational innovations.”
The Support Economy
SOURCE: Zuboff, Shoshana, & Maxmin, James. (2002). The
support economy : why corporations are failing individuals and
the next episode of capitalism. New York: Viking.

“Deep support provides ongoing
relationship based on advocacy,
mutual respect, trust, and the acute
alignment of interests.”
The Support Economy
SOURCE: Zuboff, Shoshana, & Maxmin, James. (2002). The
support economy : why corporations are failing individuals and
the next episode of capitalism. New York: Viking.
“The new digital technologies are
essential to the successful
consolidation of this new ... logic.”
Example

SOURCE: Hesse, B. W., & Shneiderman, B. (2007). eHealth research from the user's perspective. Am J Prev
Med, 32(5 Suppl), S97-103.
The Support Economy

Why important?

Just a 1% reduction would save $400 billion

Source: Leyden WA, Manos MM, Geiger AM, Weinmann S, Mouchawar J, Bischoff K,Yood JG, Taplin SH (2005). Cervical cancer in women with
comprehensive health care access: Attributable factors in the screening process. JNCI, 97(9), 675-683.
FAILURE IN SUPPORT
The Case of Cervical Cancer

Systemic Errors in Medicine

Accoun&ng
for
Two
Types
of
Error
Errors of Commission:
Doing something wrong
(root cause of detectable
errors)
Errors of Omission:
Failing to do something
right (e.g., Pap failure - leads
to more insidious
consequences)

Communica&on
Errors
at
Root
Source: Mazor KM, Roblin DW, Greene SM, et al. Toward patient-centered cancer care: patient perceptions of
problematic events, impact, and response. J Clin Oncol. May 20 2012;30(15):1784-1790.
• Interviews with 416
cancer patients across 3
clinical sites (Mazor, et al,
2012)
• Asked about events
where something “went
wrong,” the event could
have been prevented, and
the event could have
caused signiﬁcant harm.
Results*
• 28% described problem with
medical care
• 47% described a
communication problem
• 24% described problem with
both communication and
medical care
* Of those reporting error

Friedberg MW, Coltin KL, Safran DG, Dresser M, Zaslavsky AM, Schneider EC.Associations between structural capabilities of primary care practices and performance on
selected quality measures.Ann Intern Med 2009;151(7):456-63.
EHRS as Structural Capability

HITECH Act

Source: Hesse BW. Public Health Informatics. In: Gibbons MC, editor. eHealth Solutions for Healthcare Disparities. New
York, NY: Springer; 2007. p. 109-129.
Engaging Patients, Managing Populations

Meaningful Use as Building Blocks

Where are we?

Surveillance
July 27, 2012
See also: Hesse BW, Nelson DE, Rutten LF, Moser RP, Beckjord EB, Chou W-YS. National Health Communication Surveillance Systems. In:
D. K. Kim ASGLK, ed. Global Health Communication Strategies in the 21st Century: Design, Implementation, and Evaluation. New
York, NY: Peter Lang; In Press.
.
Health
Situa+onal

Awareness

*NIH Nominee to White House for “Open
Science Champion,” May 14 2013.
Data Briefs
Statistical
Guides
Peer Reviewed
Publications
Web Platform for Participation*
Health
Informa+on
Na+onal

Trends
Survey
(HINTS)
Surveillance

HINTS
Brief
#1:
Trust
in
channels

and
cancer
informa+on
seeking
Source: Hesse BW, Nelson DE, Kreps GL, et al.Trust and sources of health information: the impact of the Internet and its implications for health care
providers: ﬁndings from the ﬁrst Health Information NationalTrends Survey.Arch Intern Med. Dec 12-26 2005;165(22):2618-2624.
Surveillance

Where
would
you
prefer
to
go

for
cancer
informa+on?
Surveillance

Where
did
you
go
for
cancer

informa+on?
Surveillance

How
do
Survivors
get

their
cancer
informa+on?
Source: Hesse BW,Arora NK, Beckjord EB, Finney Rutten LJ. Information Support for Cancer Survivors. Cancer. 2008;112(11S):2529-2540.
Cancer Survivors
Patient to Survivor:
Lost in Transition?
Surveillance

Source: Hesse BW, Moser RP, Rutten LJ. Surveys of physicians and electronic health information. N Engl J Med. Mar 4 2010;362(9):859-860.
Trends:
2002-‐2003,
2005,
2008Surveillance

HITECH*
Act
passed
in
2009
*Health
I.T.
for
Economic
&
Clinical
Health
Act
Health I.T. as Foundation
for Evidence
Implementation
Source: Hesse BW, Ahern DK, Woods SS. Nudging best practice: the HITECH act and behavioral medicine Translational Behavioral Medicine. 2011;1(1):175-181.
Surveillance

Source: Jamoom E, Beatty P, Bercovitz A, Woodwell D, Palso K, Rechtsteiner E. Physician adoption of electronic health record systems:
United States, 2011. NCHS data brief. Jul 2012(98):1-8.
National Ambulatory Medical Care Survey
Supply
SideSurveillance

Health Information National Trends Survey
Demand
SideSurveillance

Building Deep Support

Two antiquated cultures in
modern times -- the mechanistic
and humanistic world views -- are
leading to a “hidden epidemic” of
error and chaos.
- Kim Vicente,
The Human Factor

Competing World Views
Mechanistic World View
• Actors: Engineers, biological scientists
• Question: How can we create new
technologies?
• Focus: Physical Object
Vicente KJ. The human factor : revolutionizing the way people live with technology. 1st ed. New York: Taylor and Francis Books; 2003.
Humanistic World View
• Actors: Social scientists, physicians
people?
• Focus: Person

RESULTS
technologies?
Vicente KJ. The human factor : revolutionizing the way people live with technology. 1st ed. New York: Taylor and Francis Books; 2003.
people?
• Focus: Person

technologies?
people?
• Focus: Person

Institute of Medicine’s “Crossing the Quality Chasm”
report

Restructuring the decisional
architectures of medicine*
Hospital Based
EHR Data
Hospital Based
EHR Data
Health Information Exchange
Medical
Team
Patient
&
Family
Hospital
System
Decision
Support
Needs
Subjective
• Chief complaint
• Patient Reported Outcomes
• Risk modeling
• Diagnostic support
• Treatment selection
• Guideline adherence
• Error detection/correction
Medical
Researcher
• Situational awareness
• Population health
• Continuity of care
• Identify side effects
• Inform discovery
Objective
• Clinical measures
• Laboratory findings
• Sensor data
Assessment
• Diagnosis
• Categorical reporting
• Prognosis
Plan
• Treatment planning
• Self-care planning
• Post treatment
• Surveillance
Source: Hesse BW. Decision Architectures. In D Bowen, M. Diefenbach, S. Miller (Eds.) Handbook of Health Decision Making.
SpringerVerlag, NewYork, NY (in press).
Meaningful Use
Safety, efﬁciency
Consumer
engagement
Continuity of care
Population health
Privacy

Source: Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review
of the recent literature shows predominantly positive results. Health Aff (Millwood). Mar 2011;30(3):464-471.
Preponderance of evidence is showing
a positive inﬂuence on care

Bringing patients into the quality
control process
• 92% of patients opened notes
• 60% reported better
medication compliance
• 77% reported being in greater
control of care
• 86% agreed that open notes
would be factor in choosing
care
• 99% wanted open notes to
continue

Patient engagement in quality control
endorsed by physicians

How often is medicine “evidence-
based”?
• Medicine gets it right 54.9% of the
time*
• Pernicious incentives divert from
evidence-based treatment**
• Explosion of information makes it
impossible to stay abreast of ﬁeld
• Historical premium on opinion-based
care
* McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med
2003; 348(26):2635-45 (June 26).
** Brawley OW, Goldberg P. How we do harm : a doctor breaks ranks about being sick in America. 1st ed. New York: St.
Martin's Press; 2012.

Create a self-improving healthcare
system, with patients as partners
Oncology as information
science: “The Learning
Health Care System”

I.T. accounts for productivity growth
in most sectors, but not Health
Friends of the
NLM Meeting
2009

But initial deployment is
disrupting workﬂow

National Research Council 2009
Report
ComputationalTechnology for Effective Health
Care advocates re-balancing the portfolio of
investments in health care IT
• Greater cognitive support for physicians,
patients, and caregivers
• Observing user-centered design principles
• Accelerating research related to health
care in the computer and social sciences
and in health/biomedical informatics

EricTopol, a cardiologist who directs the Scripps
Translational Science Institute in San Diego, says apps
that monitor blood pressure or glucose rates can be
more valuable than prescriptions to keep these
conditions in check.
"When we use a medication, we don't know if it's going
to work or not. It's much better when a person's taking
their blood pressure on a frequent basis," saysTopol.
"The average person looks at their smartphone 150
times a day, so all of a sudden they're able to diagnose
if their blood pressure's adequately controlled and what
are the circumstances when it's not."
Patients lead the way

But, with resistance ...
The Case
of Hugo

Stimulating the market for consumer-
facing apps

How do we
communicate at
“point of need,”
not just “point of
care?”

Moving toward a patient-centric
model
Source: Zuboff S, Maxmin J.The support economy: why corporations are failing individuals and the next episode of
capitalism. NewYork:Viking; 2002.
Technologies
focusing
on
the
long
term
rela&onship

with
a
customer
contribute
to
business
success*
Move away from a
“transactional”
model to a
“relationship” model

Use new infrastructure to ensure
equitable treatment across populations
Meaningful Use
Phase 3 will
emphasize
population health

Erasing the barriers between clinical
and public health

Final Thoughts

Rebuilding healthcare is like building a plane
in ﬂight ...

Meaningful Use Can Guide Redesign
Source: Hesse, Bradford W. (in press). Decisional Architectures. In M. A. Dieffenbach, S.
M. Miller & D. Bowen (Eds.), Handbook of Health Decision Science. New York, NY:
Springer Verlag.

Target: Empowered Partners

Deep
Support

Thank
you!
Slideshare.nethttp://www.slideshare.net/BradfordHesse

Hesse hopkins 2014

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