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Keeping Trains And Interoperability On Track

Fri, 04/06/2012 - 6:58am
Richard Johannes, M.D.

Dr. Dick Johannes, Vice President of Clinical Research, CareFusion

To read more from Dr. Johannes, then please read his blog at the Online Center for Safety and Clinical Excellence.

 

Recently, on our way to a morning meeting, Dr. Carlos Nunez and I got to talking about model railroads – a mutual interest and hobby. We recounted the history of Digital Command Control [DCC]—a system that utilizes digital computer technology to operate model railroad trains. DCC was first introduced in the 1990s and dramatically changed model railroad technology: For the first time, when running multiple locomotives on the same track, you could move each train in different directions and at different speeds.

Similar to most technological breakthroughs, numerous manufacturers began engineering their own early and highly proprietary versions of Command Control for model railroads. While this brought the technology to the marketplace, it introduced a new problem for users as these early approaches were incompatible with one another. We could now run trains independently on a model railroad, but couldn’t take a locomotive to friend’s house with a different system and expect it to run. 

Enter the National Model Railroad Association (NMRA) who assembled a working group to develop a common standard in model train technology. German firm Lenz Electronics gave – yes gave – their previously proprietary protocol to the NMRA to be adopted as a standard1. Suddenly, in order to obtain the NMRA imprimatur, all manufacturers had to conform to single technical standard. Not only did the technology succeed but it literally exploded. It now supports amazing lighting effects, an array of advanced automation capabilities and even digital sound. Best of all, the technology is fully interoperable. Some firms chose not to adopt the common standard and eventually disappeared. But most of those who embraced the NMRA DCC standard continue to thrive today. 

It was at this point in our discussion that Carlos asked, “Where is the NMRA for healthcare?” Great question! Today, CMS is creating incentives for hospitals to adopt enhanced healthcare information technology (HIT), introducing new concepts and standards like “meaningful use.” But what is the future for widespread interoperability in healthcare and what will that journey require?

To me, one of the benefits to interoperability is that it changes the criteria for success from simply having the data to what can be accomplished with the data. It’s about transforming data into actionable information. Consider the following patient data elements: Age, obesity, bed rest, use of hormone replacement therapy or oral contraceptives, planned major surgery, known diagnosis of cancer, history of venous thromboembolism [VTE] and hypercoagulability. This data comes from varied sources – the ambulatory electronic medical record, the laboratory system, the admission diagnoses, the order entry system and the patient’s medication list.

But when you bring them all together, a score can be calculated, and if that score reaches four, a computer algorithm could search the order system for evidence of mechanical or pharmacological prophylactic measures to prevent venous thromboembolism. The absence of such prophylactic orders creates the opportunity for an electronic intervention in the form of a recommendation for VTE prophylaxis.

Several years ago, investigators at the Brigham and Women’s Hospital in Boston2 set out to understand if such an intervention had quantifiable merit. They established a study, assigning patients to either the use of electronic alerts or to the conventional standard of care. The primary end point was deep-vein thrombosis [DVT] or pulmonary embolism [PE] in 90 days. The results were stunning. The algorithm reduced the risk of DVT or PE in 90 days by 41 percent. What’s even more impressive is that the prophylaxis compliance rate in the intervention group was only 33 percent. Of course, some of the cases had clear reasons not to anticoagulate, but that does not explain why mechanical measures were not employed. Better data always opens the door of opportunity, but that door will often have surprising new doors behind it. 

This year’s annual HIMSS conference continued to prioritize the importance of interoperability in the meaningful use era but at the same time balanced the magnitude of achieving interoperability as a challenge that faces the healthcare industry overall.  There’s no doubt that interoperability is a monumental goal for healthcare3,4,5.  But, how is it going to happen; who’s going to lead the way, and when?

Bio for Dr. Dick Johannes, Vice President of Clinical Research, CareFusion

Growing up on a dairy farm in central Wisconsin, Dick Johannes never imagined he’d one day be named chief medical resident at Johns Hopkins Hospital or go on to become an advisor to former president Jimmy Carter and the Carter Foundation. It’s the diversity of healthcare, the changing nature of the industry and the ability to work with patients and practitioners of different backgrounds that continues to inspire him today.

Dr. Johannes is currently vice president of Clinical Research at CareFusion. In addition to his clinical practice, he previously served as a faculty member in gastroenterology and biomedical engineering at The Johns Hopkins University School of Medicine. He has served on several National Quality Forum (NQF) committees related to public reporting of health outcomes and is the current CareFusion representative to the NQF.

Dr. Johannes earned a bachelor’s degree in chemistry from the University of Wisconsin, a doctor of medicine from The Johns Hopkins University and a master’s degree in computer science from The Johns Hopkins University.

References:

  • Polesgrove M,DCC Projects and Applications. Kalmbach Publishing, 2006.
  • Kucher N, Koo S, Quiroz R, Cooper JM, Paterno MD, Soukonnikov B, Goldhaber SZ. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005 Mar 10;352(10):969-77.
  • James B. E-health: steps on the road to interoperability. Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives:W5-26-W5-30.
  • Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009 Apr 16;360(16):1628-38.
  • Kuo MH, Kushniruk AW, Borycki EM, Hsu CY, Lai CL. National strategies for health data interoperability. Stud Health Technol Inform. 2011;164:238-42.
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