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2 A Vision for 21st Century Health Care and Wellness The Institute of Medicine (IOM) defines health care quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge,” and in recent years, a broad consensus has emerged on the future health care environment. In the words of the IOM, health care should be:1 • Safe—avoiding injuries to patients from the care that is intended to help them. • Effectie—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit, avoiding underuse and overuse, respectively. • Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. • Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care. • Efficient—avoiding waste, including waste of equipment, supplies, ideas, and energy. • Equitable—providing care that does not vary in quality because of 1Institute of Medicine, Crossing the Quality Chasm: A New Health System for the st Century, National Academy Press, Washington, D.C., March 2001. 

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0 COMPUTATIONAL TECHNOLOGY FOR EFFECTIVE HEALTH CARE personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. The IOM vision calls for a health care system that is systematically organized and acculturated in ways that make it easy and rewarding for providers and patients to do the right thing, at the right time, in the right place, and in the right way. This vision entails many different factors (e.g., systemic changes in paying for health care, an emphasis on disease pre- vention rather than disease treatment). But none is more important than the effective use of information.2 Based on its observations and expertise, the committee identified a number of information-intensive aspects of the IOM’s vision for 21st century health care. Each bullet phrase below summarizes one of these important health care IT capabilities, followed by an illustrative vignette of what might be possible. The vignettes (displayed in italic type) are not comprehensive (i.e., they do not cover all aspects of the capability). • Comprehensive data on patients’ conditions, treatments, and outcomes. A clinician needs to know what medications an elderly, memory- challenged patient is taking. Recognizing the important difference between medications prescribed and medications taken, the clinician asks the patient to bring all of his pill containers, both prescription and oer-the-counter, to the appointment. She asks the patient to place all of the containers on a surface table computer, which automatically identifies the medications in each of the containers and counts the num- ber of pills remaining in each container. The pill containers also carry RFID [radio-frequency identification] tags, on which the initial fill-up quantities of the containers are stored. The table can read these tags, and thereby make an inference about what pills were actually taken and proide information about likely compliance with a particular medica- tion regime. Farther in the future, recognizing the differences in how 2Institute of Medicine, The Computer-Based Patient Record: An Essential Technology for Health Care (Revised Edition), National Academy Press, Washington, D.C., 1997, available at http:// www.nap.edu/openbook.php?isbn=0309055326; Institute of Medicine, Key Capabilities of an Electronic Health Record System: Letter Report, The National Academies Press, Washington, D.C., 2003, available at http://www.nap.edu/catalog.php?record_id=10781; Institute of Medicine, Patient Safety: Achieing a New Standard for Care, The National Academies Press, Washington, D.C., 2004, available at http://www.nap.edu/openbook.php?isbn=0309090776. 3If purchase history were available to provide information on when the container was filled, inferences could be made about the frequency and timing of pill-taking, rather than only the total number of pills taken.

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 A VISION FOR st CENTURY HEALTH CARE AND WELLNESS indiiduals absorb or clear medications from their bodies, a blood sample of the patient in question is analyzed with a mass spectrometer or other similar deice, and the resulting spectrum identifies the actual leel of all drugs in the patient’s body. Combined with information from the smart table, a profile of the patient’s compliance and pharmacokinet- ics for each drug is generated. The clinical significance of the smart medications table and the mass spectrometer is that together they help to reduce uncertainty by synthesizing different iews into the patient’s medication history. • Cognitive support for health care professionals and patients to help integrate patient-specific data where possible and account for any uncertainties that remain.4 A primary care clinician needs to monitor a patient’s heart condition. Cardiac information is proided to the clinician not in the form of tables of numbers or indiidual EKG plots, but rather as an oerlay on a isual animated structural model of the patient’s heart (not a generic heart) deried from arious imaging modalities. The system displays the rel- eant functional information in summary form and proides an image of the heart in operation drien by all of the data that hae been collected about the patient oer time. Different time scales are aailable for dis- play, and the clinician can display an animated image of the patient’s heart in operation as the patient is resting or exerting himself (i.e., in near-real time), or track how the structure of the heart has changed oer the last  years using time-lapse-like sequences. Functional histo- ries are also aailable. Histories are instantly aailable in easy-to-read form, with different parameter histories presented on similar-looking charts normalized to z-scores and timescales, showing upper and lower “normal” and physiologic bounds. The clinician also has the ability to drill down to any supporting piece of information that underlies the display. The clinical significance of an animated structural model is that it drastically reduces the cognitie effort needed for the clinician to isualize the heart functioning in this particular patient, freeing her to use those cognitie resources for other related tasks. The model also helps the patient to understand the medical situation at hand and assists both clinician and patient in determining an appropriate course of action. 4In this report, “cognitive support” refers to IT-based tools and systems that provide users (clinicians and patients) with the information, abstractions, and models needed to achieve the IOM’s vision of health care quality. 5See, for example, Seth Powsner and Edward Tufte, “Graphical Summary of Patient Sta- tus,” The Lancet 344(8919):386-389, August 6, 1994, available at http://www.stottlerhenke. com/projects/IPDRA2/info_resources/powsner_tufte_graphical_patient_summary.pdf.

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 COMPUTATIONAL TECHNOLOGY FOR EFFECTIVE HEALTH CARE • Cognitive support for health care professionals to help integrate evi- dence-based practice guidelines and research results into daily practice. A primary care clinician has a number of patients with arious heart conditions. In order to help stay current with recent literature, he sub- scribes to alerts from the medical literature and learns that a particular heart disease guideline has been updated to include a new drug that reportedly preents a difficult and expensie complication. After com- paring it to other guidelines that he beliees to be trustworthy, he decides to incorporate this new guideline into his practice. By clicking on a link, the clinician can download the guideline to his system, which also searches for and constructs seeral potential action flowcharts to meet the guideline’s goals, based on an internal computable model of clinic workflow and resources. He selects one and his disease management dashboards, order sets, and reminder systems are updated. (A dashboard is an easily iewed display that summarizes the health status of multiple patients.) The clinical significance of the literature alert system is that it enables the clinician to keep current and to systematically translate new knowledge into his practice while enabling the clinician and the patient to decide on the appropriate course of treatment. • Instruments and tools that allow providers to manage a portfolio of patients and to highlight problems as they arise both within individual patients and within populations. The computer of an outpatient care proider displays the summary health status (a “dashboard”) of her 00 diabetic patients with color- codes and carefully designed graphical displays for clinical measures of the disease (blood sugar leels, AC counts, and so on) that proide rapid assessment, at a glance, of the status of all patients: those who are managing illnesses successfully, those requiring interention, and those who are marginal cases. When a diabetic patient isits her, the system reiews applicable guidelines, customizes an order set to the patient’s state and insurance plan (e.g., picks the preferred drug from the drug class), and reminds the physician to discuss the selected drug with the patient. Feedback indicating success is proided when the proider sees that the display indicators of her patients show successful management. The clinical significance of a summary health status display is that it gies the proider prompt feedback about where her attention is most needed in time to take correctie action. • Rapid integration of new instrumentation, biological knowledge, treatment modalities, and so on, into a “learning” health care system that

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 A VISION FOR st CENTURY HEALTH CARE AND WELLNESS encourages early adoption of promising methods but also analyzes all patient experience as experimental data. A pediatrician in Los Angeles finds herself working with an eer grow- ing set of young patients with seere asthma. A group of them hae added her to their Facebook page where they run a special widget that shows her when and where they did moderate or high physical actiity outdoors. The application does not rely on self-reporting. Rather, the young people run an application on their mobile phones that uploads an SMS message containing their current location eery 0 seconds to a priate account where an application processes and summarizes loca- tion-actiity data generated from accelerometers on their phones. The doctor has recently introduced a new feature whereby her patients use special Bluetooth-equipped inhalers that report ia the mobile phone each time the inhaler is used. The website then displays when and where they used their Bluetooth-enabled inhalers. In addition to iewing trends oer time, and patterns based on time of year and day of the week, she runs an application that relates her patients’ actiity to real-time pollution expo- sure models made aailable by the city. She uses the data to make a case to the city about other possible actiity locations (e.g., different outdoor parks) and is soon going to enable her patients to sign up for automated customized alerts when they are oerexerting themseles under hazard- ous enironmental conditions. The clinical significance of an automated actiity reporting and processing system is that it proides reliable data on what patients actually do (rather than what they say they do) in a form that is easy to understand, as well as additional detail to link to other data sources to clarify patterns, and deliery that is timely enough to support real-time feedback in time to change behaior. • Accommodation of the growing heterogeneity of locales for the provision of care, including home instrumentation for monitoring and treatment, lifestyle integration, and remote assistance. A diabetic patient wears an actie sensor that proides continuous blood-sugar readings. When these readings approach leels that indi- cate that actions need to be taken (e.g., taking an insulin shot, eating something), the sensor proides an indication to the patient. Acting with the patient’s prior consent, if the patient fails to take the necessary action (as would be indicated by increasingly dangerous readings), the sensor communicates with a cell phone to place a call to an emergency caregier. Along with the patient’s ital signs and intake information (name, present location, and so on), the call also proides a summary of the releant readings so that the caregier can be dispatched to the site

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 COMPUTATIONAL TECHNOLOGY FOR EFFECTIVE HEALTH CARE of the emergency and be prepared for what action should be taken. The clinical significance of an actie sensor is that emergency interention can be requested in the absence of patient action, and that the emergency response can be proided in adance with information that would other- wise hae to be gathered immediately upon arrial. • Empowerment of patients and their families in effective manage- ment of health care decisions and execution, including personal health records (as contrasted to medical records held by care providers), educa- tion about the individual’s conditions and options, and support of timely and focused communication with professional health care providers. The son of an elderly man hospitalized by a stroke needs to know about his father’s medical condition. Rather than waiting for hours by his father’s bedside to intercept a physician on rounds so that he can obtain authoritatie information, he logs into a secure application that makes his father’s electronic health record (EHR) aailable on the Internet. But since he is not a physician himself, he inokes a data interpreta- tion application that examines the data in the EHR and proides in lay language a summary of the important aspects of a patient’s medi- cal condition, preiously proided treatments, and treatment options under consideration. The application proides an interpretation (and the reasoning behind the interpretation) that is comparable to that which an experienced clinician could proide. The clinical significance of an automated EHR lay interpretation system is that the family can be kept in the decision-making loop, in a culturally sensitie way and on a more timely basis than is possible today, and potentially aoid delays often inoled when families need time to make decisions—since they learn releant facts sooner (perhaps een days sooner), they can start the process sooner. In addition to the data flowing from caregiers, the son can also enter information based on his knowledge of his father’s present state and medical history, proiding caregiers with another source of information, and empowering the son to hae a greater role in his father’s treatment.