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Well, again, I'd like to frame my comments using the five rights of
clinical decision support that we talked about earlier.
And again, the issues here is: how can we use information
interventions to drive improved care processes and outcomes.
And I think one of the exciting things about this paper is it
talked about outcomes that people can really sink their teeth into.
We're talking about patient satisfaction;
caregiver satisfaction; potentially,
clinician satisfaction; and then, most important,
things like morbidity and mortality.
So, we're talking about a CDS information intervention to really
drive core improvements in things that all the stakeholders care
really deeply about.
So, with the last paper, again this paper anchors us on the
channel dimension of those five rights.
And the channel that we're talking about is interactive health
communication systems.
And it sort of raises the question-- that's a very highly
interactive medium, so it opens up lots of very exciting
possibilities and then raises a bunch of other implications for
the other dimensions of those five rights.
So with, as far as individuals, we're not only talking about
clinicians and patients as we talked about last time,
but caregivers are also a central piece of this mix.
Again, opening up lots of opportunities to intervene and
drive improved outcomes.
And when it comes to workflow or thought-flow,
we're thinking again about how each one of those different
stakeholders - the clinicians, the patients and the caregivers - what
they're doing during the course of a day;
what their thought processes are; and how we might intervene in
those with these information interventions to drive these
improved outcomes; and then the formats,
the same formats that we talked about last time.
We're talking about things like alerts, state of display,
data gathering; things like that.
But with the additional twist of doing that in an interactive,
shared sort of way, which is the essence, I think,
of this channel that we're talking about.
And then when we talk about the specific information that we're
delivering, that takes us back to AHRQ in the Eisenberg Center,
raising the question: how can this channel be leveraged against the
specific kinds of content that AHRQ has available to disseminate;
and the specific objectives it is trying to achieve by disseminating
that information.
I think it's important to point out that this paper sort of
focused on the interactive channel for cancer.
But I think the lessons, as were noted earlier with the CHESS
system, are more widely applicable.
And the fact that there was this intriguing hint of a mortality
benefit, I think really raises an issue that we're not just talking
about drugs and surgeries as prolonging outcomes,
that these interventions themselves can become tools.
And I think that opens up a lot of very exciting possibilities
and opportunities.
So, one of the things that I think is critical about the interactive
notion of this particular channel is it takes us beyond
the reference paradigm.
We're not opening up peoples' heads and pouring information
into it as it has been noted a number of times.
And a quote from the paper, I think really drives that home:
"A new identity as a patient is established;
complicated treatment decisions are presented; physical,
emotional and spiritual challenges emerge.
For a patient to be fully engaged in health decision-making they
need to interact with fully engaged clinicians."
So, I think this opens up-- this puts an even sharper focus on:
how can these information interventions help make sure that
all these good things happen?
So, how do we put the evidence into action so that it's actually
driving improvements and quality of life and,
perhaps length of life, rather than just, "Okay,
we've given you the information so now we can cross that
off the list."
One of the things that I really liked about this paper and that I
thought was highly valuable is that: when we think about the
workflow dimensions so, the right information, the right people,
and then thinking about the workflow,
the paper laid out a very specific sequence.
And it described it in terms of the cancer process,
but I think it's much more widely applicable to healthcare
decision-making.
And this was hinted at in some of the other papers
and presentations as well.
But in this particular paper they described the steps of "Informed;
Deliberate; Decide; Implement; and Evaluate."
And so that lays out the workflow.
So when we think about the assets that AHRQ has and how those might
be disseminated, thinking about it in terms of those individual
workflow steps.
And either which information is pertinent or how should that
information be honed so that it's dealing with the specific needs
and challenges of each one of those workflow
or thought-flow steps?
And then, so what does the right tools look like;
what does the right information look like to address the needs at
each one of those stages?
And then the comment was made in the paper that the system should
ultimately be integrated with electronic medical record systems.
Obviously those systems are brought to bear both the systems
that the clinicians use as well as personalized health records
that patients use.
Those systems play a different role in each one of those steps,
I think. It sort of lays out, in a fair amount of detail,
a framework for thinking about how to drive these information
interventions so that they optimally facilitate each
one of those steps.
So, the point about supporting patients' understanding of complex
diseases, so: what information does it take to do that?
And I think again, the paper pointed very specifically to some
kinds of information needs and information support that
are pertinent.
So, this was mentioned in terms of the caregivers but I think it
applies to the other stakeholders as well.
So care-giving responsibilities include: monitoring symptoms,
dealing with unpleasant side-effects;
providing emotional instrumental support to the cancer patients.
Caregivers also play an important role in information gathering and
sharing and the decision-making process.
So, I think this sort of begs the question: what sort of
evidence-based tools might be helpful in supporting these
critical and complex tasks?
I think another thing, getting back to the notion of
interactivity, it's not just a matter of informing patients,
or informing clinicians, or informing caregivers,
as this quote points out.
Yet, despite these potential positive aspects of accessing
health information, to some the information's overwhelming,
increases awareness of conflicting cancer information,
and can raise doubt about the right course of cancer treatment.
So, it's not about informing or guiding a bunch of people
separately, it's about getting all the stakeholders on this team on
the same page.
Drawing their information from, at least,
a common source that has a common basis in evidence and sort of,
again, prompting the question: how can AHRQ provide content and tools
that will not only inform folks individually but help get
everybody altogether on the same page?
One of the other five rights of CDS is: using the right
intervention type. And I was pleased to see,
in this paper and in the work of CHESS and Lori and her team,
the fact that a very broad array of intervention types
is brought to bear.
So, the paper says that CHESS provides algorithms,
decision rules, feedback and prompts,
there's data gathering tools.
So, there's a health status assessment which supports
documentation and then that documentation is linked to
pertinent evidence illustrating how you can link together various
CDS interventions to an overall portfolio of things to help drive
specific improvements.
And I thought one of the very compelling pieces of the whole
project was the clinical report.
So, that really chains together three different intervention
types: the documentation tool, relevant information for the
clinician, as well as alert.
So I think, again this provides a fairly sharp series of things that
AHRQ and the Eisenburg Center consider,
in terms of how to take this evidence and translate it into
these tools that will combine these different intervention types
to drive toward the outcomes.
One of the things that I wanted to emphasize,
which Lori emphasized as well, getting back to this theme of
doing clinical decision support with the recipients and not to
them, I was impressed with the degree of detail that was
described about the needs assessment part of this work.
I mean, the sentence here was, "It is critical that such systems are
designed around the needs of those they plan to serve,
offering functionality that clearly fulfills the need."
I mean, it seems like that should almost go without saying,
but it doesn't go without saying because a lot of the problems that
we've had in clinical decision support is that we fail to really
think in great detail about who it is that we're trying to affect,
and what their needs are, and how we can best support them.
And in this project a tremendous amount of attention was devoted to
that and I think that's an important part of the reason of
why this work has been so successful.
So for me, that sort of raised the question of whether and how the
Eisenburg Center, and Rick and I were talking about this a little
bit at the break, to what extent there's the latitude and the
capability to do this sort of needs assessment,
to ensure that the interventions, that the organization,
does come up with-- will in fact drive the outcomes that are trying
to be accomplished.
And again, I would end with this notion of the mortality benefit.
I mean, the fact that we literally are potentially talking about a
life-prolonging intervention, so these things are, in a sense,
part of the treatment themselves, I think raises a lot of very
important issues that warrant further investigation and
analysis, as we would with any promising compound of surgery
or anything like that.
So, with that, thank you.