The white coat of a physician signifies a 19th century model of leadership: authoritative, unchallenged, above and beyond the ordinary. This is not who today's physicians are. They nurture, they collaborate, they understand the importance of every member of the patient care team. Health care management, though, has kept them in the last century. Radical change is not an option any more; it is necessity.

Problem

The current buzzwords in the health care debate are evidence based medicine and electronic medical records. Great effort and expenses have been lavished on transforming medicine to standardize processes, use electronic databases to share information across providers, and use the results of clinical trials as basis of decision-making in patient care. Why, then, are we making progress at a pace that caused my colleague to quip that "Academic Medical Centers are the only glaciers not affected by global warming"? Try instituting 21st century management methods with mid-20th century technology.

Evidence based medicine requires all physicians, in all specialties, to keep abreast in their professional reading of dozens of publications presenting the latest trial results. For each of these peer-reviewed publications, it is nevertheless left to the judgement of the physician reader to evaluate the scientific rigor and quality of the studies. These same studies are not accessible free of charge to other members of a patient care team such as nurses or Radiation Therapists, nor written in a language that can be easily digested by anyone even remotely tangential to the specialty. Only 5-10% of patients even in the most ideal circumstances are enrolled in clinical trials in academic medical centers because of the stringent eligibility criteria and immense work required per trial patient.

While most of the larger medical centers have switched to electronic medical record (EMR) systems, these systems do not exchange information outside the immediate healthcare organization, e.g. between a hospital and a primary care physician in private practice. The majority of EMRs are an excellent data repository, but provide scant to no tools to mine the data to get information on the outcome of care. This, in turn, leaves the individual physician and their supportive staff without feedback on their performance in comparison to any best practice standard. Physicians, left without any practical way to get information about the quality of their practice, are continuing business as usual because there is no reliable data driving the need for change.

Solution

Web 2.0 can help. Rather than publishing the results of evidence-based studies in an ever growing array of scientific publications, we need to build a Wiki to give physicians direct and easy access to the most relevant information for their patients. Google Health failed precicely because it was lacking the input from the very people who drive decisions of care: physicians and nurses.

Let us look at a very well defined example where standard of care affect 1/3 of American men during some point of their life: prostate cancer. Our new MedWiki will have a well defined decision tree structure based on pathology and staging. Within each subcategory, researchers will be able to provide information on their latest published study: treatment modality, outcomes, patient cohort size, risk, study phase, statistical significance. A link from within the EMR will direct the physician immediately to the MedWiki page relevant for this specific patient, summarizing in one page the current standard of care studies to enable the physician to choose the care plan for best expected outcome.

In a second implementation level, EMRs will be re-designed with core functions defined by people on the the hospital floor such that they will automatically collect, process, and summarize practice outcome for patients for any care provider relative to the national average. For example, each Radiation Oncologist should have easy access to the survival rates for the patients in his care without having to initiate a study requiring several months of an academic sabbatical. To build the technological framework for this data, we need to standardize EMR systems and require the capability to communicate a complete set of patient healthcare information between all physician care providers independent of their practice location.

Practical Impact

A physicians goal is simple: Caring. The new Web 2.0 tools will assist them to do exactly that, providing their patients with the best possible care. The current amount of avoidable medical errors is only the tip of the iceberg of millions of patients caught in the invisible care gap that exists between one standard deviation of best practice and the outliers constituting reportable events. By bringing these areas of suboptimal care to the physicians attention via the MedWiki best practice recommendations and the EMR data mining comparison of individual practice outcome to a national standard, we will be giving physicians the tools for meaningful continuing performance improvement. The practical impact will transform the practice of medicine as radically as the simple act of washing hands between patients. The benefits of good health, and giving each of us a good shot at returning to the best health achievable after a brush with a serious illness, do not need to be restated here. In our collective pursuit of happiness, it is also the right thing to do by our fellow citizens.

First Steps

The first two steps toward a vision of Web 2.0 supported practice can be taken in parallel:

The IHE project is already working in defining software standards for EMR systems to improve information exchange. With added support from healthcare providers through financial incentives for implementing EMR and EMR interfaces, the movement away from the paper chart will gain speed.
Wikis already exist for a multitude of Web2.0 applications, from the ubiquitous Wikipedia to the recent additions of German Wikis studying PhD theses of prominent politicians and scientists for plagiarism. A dedicated core team to build the Wki structure, supplemented by volunteers in good Web 2.0 tradition, will need to be funded to get the paradigm shift started. Cloud computing and Wiki software has brought hardware costs down significantly; funding for salary support of the core team needs to be raised by a combination of grant support, private donors, and through patient advocacy groups.

The third step, implementing EMR tools to analyze practice-based outcomes vs a national standard, and gathering data to define the national standard, is the most challenging aspect of this proposal. As healthcare providers and managers in the health care sector, we need to make the availability of patient outcome analysis tools within any EMR system a major criteria for driving purchasing decisions of EMR software. Customer demand will need to drive the industry agenda here. Gathering national standard data on a meaningful level and with significant volume to have statistically signifcant patient cohorts for analysis requires us to move away from the concept of clinical trials as the only way to create evidence-based medicine. Patient registries, casting a much finer net to collect more, and more relevant, data for database mining need to be developed.

Credits

Conversations with coworkers, professional peers and most importantly, patients, have initiated my thoughts on what we need to do to radically transform a healthcare system which has existed in the current from for almost a century. Dr Robert Timmermann from UT Southwestern, TX, has been a tireless advocate for patient registries. Drs Sarah Donaldson and Lynn Million, with their clear flow chart for treatment of pediatric sarcomas, gave me the idea for the Wiki structure. Animated lunch discussions with Agam Sharda have helped me verbalize the vague concepts in my mind.

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