The Third Wave, Informatics, Quantum Mechanics and Health Care Reform

Schrödinger's cat

While the Population Health Blog continues to mull the promise vs. reality of Alvin Toffler's book on The Third Wave "Information" Age, it's been struck by the observation that any Wave's ideals are often applied to institutions.

It's a classic chicken vs. egg self-reinforcing feedback loop. For example, during the Second Wave, the industrial mindset gave rise to bureaucracies. 

Which prompts the PHB to wonder if the electronic health record (EHR) was the inevitable result of the Third Information Wave, or its intrusive invention?

Whither Biology in Health Care's Third Information Wave?

Yet, at the same time, the physician PHB has been struck by the emergence of biology-laced health reform jargon.  It's not unusual to read or hear that care delivery should have "organic" features (e.g., here and here) and resemble "ecosystems" (here and here).  Indeed, the intellectual underpinnings for integration is eerily close to complex 'living" entity, with a whole that is more than the sum of its semi-autonomous parts.  Think more organism than organization.

Biology: Not Incompatible but Synergistic

And before you assume that the healthcare paradigm of binary silicon-based electronics is  incompatible with complex carbon-based life forms, recall that DNA has been recast as a computer, and life has been defined as a DNA software system. Is networked machine intelligence in a large regional delivery system all that different than the chromosomes and enzymes that enable me to type this blog?

It seems that the "biology" of "information technology" is not cognitive dissonance, but a perfect, if ironic, window into where health care is headed.

Enter Statistics

And since software is ultimately about information, "medical informatics" has - by definition - moved front and center. Assuming it is "patient-centric," success in our Third Information Age is less about collecting patient anecdotes than their associated data: assembling and using of means, standard deviations, p < .05 significance, associations, predictors, regressions, known-unknowns, unknown-unknown Black Swans, artificial intelligence and "big data" inputs. Little wonder, then, that the informatics underpinnings of "population health" are increasingly being used by policymakers and has captured the attention of the entities such as the Institute of Medicine, and The White House.

Statistics on Steroids: Quantum Mechanics and What We Don't Know

Quantum mechanics is bubbling up into popular media (from photography to leadership). Health care - from the atomic level  of molecular biology to the societal level of public health - has not been immune.

Mix quantum mechanics with some Triple Aim, and Heisenberg's "Uncertainty" over position vs. momentum tells us that the more intense the statistical measurement of health care quality and cost, the greater the complexity, impreciseness and chaos. 

If so, it may be that the best that health system architects will ever be able to do is define the range of probabilities, risk and uncertainty that underlie cost, quality and care. 

Which leads the PHB to......

Risk as the Coin of the Healthcare Realm

Insurers are masters at measuring and monetizing (and, when necessary, avoiding) health risks. They understand the inherent uncertainties of health care. In the PHB's estimation, the quantum sophistication of the Information Age is going to lead the next level: managing uncertainty.

The Bottom Line: Outcomes vs. Risk Management

As health informatics and analytics grow, health care's imprecision will become better defined. We'll understand that not every patient with diabetes will be known to have diabetes, not every patient known to have diabetes will have a test for diabetes and collecting all individual tests for diabetes will never tell us what's really going on for the universe of diabetes.  The idea that we can use the health system to attain 100% measurement or perfection is about as real as the quantum state of Schrödinger's cat.

OK, What About the Real World?

While quantum mechanics already has some real world applications, it's too early to predict how risk, uncertainties and probabilities will factor into the future of health reform.  But the PHB confidently predicts that patient outcomes will be less a function of diabetes control, rehospitalization rates, medication compliance or satisfaction. 

Instead, it will be about understanding the determinants of a lower risk of diabetes complications, a lower chance of rehospitalization, a greater likelihood of medication compliance and a higher probability of satisfaction.  Quantum mechanics tells us that when measurement causes these well-managed probabilities to "collapse" out of their "quantum" state, the measurements will look better.

All that remains is determining the best combination of buyers, payers, insurers, providers and government necessary to achieve that.

It starts with the risk.  Complex health systems that adapt to that fundamental paradigm shift will win.

Image from Wikipedia

The EHR Tipping point, HEDIS® Uncertainty Principle and the Hypoplastic Hypothesis

(From time to time, the Disease Management Care Blog welcomes commentary from its readers.  Here's an interesting thought.....)

As a long-term reader, I thought the erudite but contrarian and sometimes snarky DMCB might be the best venue to ask others of my ilk to comment on an observation of mine.

I am a primary care provider working at the quantum level of patient care.  I am in my second year of full fledged EHR use.  It is obvious to me from the consultation notes that I receive on an hourly basis that most of my colleagues are also on board.  Journal articles as well as my first-hand experience have convinced me that we have indeed reached the tipping point of electronic record use. 

Since this milestone passed, I have noticed a change in the focus of office notes and consults.  I am seeing neurosurgeons document conversations regarding the safety of patients relationships and whether or not they feel threatened.  Podiatrists routinely document the existence of living wills.  Dermatologists are now savvy about the sexual activity of octogenarians with actinic keratosis. Despite my consultants' thoroughness in their care (and conversations with health care students who have rotated through these specialties make me believe that some specialists are using telepathy to document things), I am not seeing traditional assessment and plans at the end of the encounter. 

What I usually see is the same generalized diagnosis code that I sent them with followed by a list of tests cluttered with a references to various quality metrics that are inspired by systems such as HEDIS®.  The old fashioned differential diagnoses or thoughtful prose concerning the evaluation is conspicuously absent. 

I call this my hypoplastic hypothesis.

As a primary care physician, when I consult a colleague, I am really asking the specialist “Hey, what do you think?” Prior to the advent of the EHR, much of my continuing medical education has come from the insights that I use to get from these consults. Now I'm reading about feeling threatened, living wills and sexual activity.
 
How did we get here?

When I was an undergrad in Biochemistry, during the dreaded Physical Chemistry course, we learned about the observer effect and the Heisenberg uncertainty principle. Wikipedia defines both as:

"In science, the term observer effect refers to changes that the act of observation will make on a phenomenon being observed. This is often the result of instruments that, by necessity, alter the state of what they measure in some manner. A commonplace example is checking the pressure in an automobile tire; this is difficult to do without letting out some of the air, thus changing the pressure. This effect can be observed in many domains of physics.....However in quantum mechanics, which deals with very small objects, it is not possible to observe a system without changing the system, so the observer must be considered part of the system being observed.

In quantum mechanics, the uncertainty principle is any of a variety of mathematical inequalities asserting a fundamental limit to the precision with which certain pairs of physical properties of a particle known as complementary variables, such as position and momentum, can be known simultaneously. For instance, the more precisely the position of some particle is determined, the less precisely its momentum can be known, and vice versa."

In my opinion we now have a new phenomena that parallel the laws of physical chemistry:  I call it the HEDIS uncertainty principle. 

The actual act of measuring HEDIS® scores and other similarly contrived quality metrics has fundamentally intruded into the quantum level of physician care.  Does this measurement change the behavior of the particles of the system and alter the ultimate structure of the encounter?  Are the data still reliable and the measurements still accurate?  Have the impressions and treatment recommendations indeed become hypoplastic, or has the encounter remained unchanged but the documentation is skewed to HEDIS®? Is the question asked of the consultant answered but not documented?  If not, what does this portend for disease management and health care quality?

I have my suspicions, but I would like to tap the wisdom of the DMCB readers for theirs.

Image from Wikipedia