I think we need to separate the role of the quality improvement/monitoring (where quick access to medical records should prove invaluable) from discovery efforts (where the use of EMR will not revolutionize clinical research as it is often portrayed). As we argued in our paper [ Implications of the Principle of Question Propagation for Comparative-Effectiveness and “Data Mining” Research (JAMA Jan 19, 2011)], and which I sent to Jim in a separate e-mail, data-mining of EMRs to discover effect of new treatments etc will, due to fundamental epistemological reasons, always remain hypothesis-generating exercise (invariably requiring further prospective data collection to refute or corroborate the retrospective nature of EMR data-mining). I personally believe that the current fad about collecting blood and tissue samples for genomic analysis to be later correlated with EHR records is huge waste of resources (and this is going on in every single institution across the US and probably elsewhere). This, of course, is not criticism of Jim's phenomenal efforts and his reputable organization- I am only reminding people of basic principles of philosophy of science that tend to be forgotten as new gadgets are being invented.
Let me know if you need a copy of the paper
Ben
Sent from my iPad
On Nov 6, 2011, at 11:17 PM, "Dr. Amy Price" <[log in to unmask]> wrote:
> Hi Jim,
>
> Thank you, This is how I was hoping the results could be used for as
> improved outcomes in conjunction with evidence based care processes. I like
> the concept of genomics inclusion a lot, in fact I wondered if this was
> possible. I am interested in the diabetes and how you brought them into
> effective care, this is really such an important contribution and the
> cardiovascular intervention improvements are huge.
>
> I understand people emphacizing the qualitative aspect and their fears in
> this regard but I see a lot of people where critical information is just
> missing and that makes any kind of intervention less effective and more
> costly in time and resources plus I think identifying patterns of successful
> care and rejecting those that look good in the lab but don't work in real
> life would help everyone.
>
> I appreciate this information and your response,
>
> Amy
>
>
> -----Original Message-----
> From: Evidence based health (EBH)
> [mailto:[log in to unmask]] On Behalf Of Jim Walker
> Sent: 06 November 2011 10:39 PM
> To: [log in to unmask]
> Subject: Re: Evidence-Based Medicine in the EMR Era
>
> Hi Amy.
>
>
> First, to the very far from easy--granting the accuracy of what Marguerite
> says:
> For most useful analytics, we combine information from the EHR and 12 or so
> other databases (including claims) into a data warehouse, where all but the
> simplest analytics are performed. The normalization of this data is a
> painstaking process. Recommendations are then fed back into the EHR, the
> only interface that most of our clinicians use. (Our Keystone Beacon
> Community has developed a community data warehouse to which different
> organizations contribute their data to support shared care processes across
> five rural Pennsylvania counties.)
>
>
> Second, most of our analytics begin with evidence-based care processes, not
> trolling for correlations. (Kaiser has the numbers for doing this more
> effectively.) Beginning with process measures that have been validated as
> leading to improved outcomes (e.g., retinal exams for people with diabetes),
> we create care processes to assure that the interventions are offered to
> patients 100% of the time. Then we measure process performance and patient
> outcomes looking for correlations (or lack thereof) to guide process
> refinement.
>
>
> For example, our cardiovascular surgeons identified 38 interventions they
> believed to have been demonstrated to reduce complications in patients
> undergoing elective CABG. At the outset, our patients got them 69% of the
> time (better than national benchmark). Within 3 months of re-designing the
> process and fitting the EHR to support the team, we were at 95%. We have
> been above 98% for the last 2 or 3 years. Outcomes such as return to work,
> rate of wound infections, etc. have tended to improve, some of them
> statistically significantly. Correlations between individual interventions
> and outcomes are performed regularly, with adjustments in interventions
> based on the results.
>
>
> Using this approach in our patient-centered medical home, we have decreased
> all-cause admissions in a population of 22,000 Medicare patients.
>
>
> We currently are using this approach with 15-20 acute problems (e.g.,
> cataract surgery) and another 15-20 chronic problems.
>
>
> We also scan the database (primarily EHR data) for, e.g., patients with GFR
> < 60 but without any record of assessment or management of CKD and patients
> with HbA1c > 7 and no management of diabetes. We have identified thousands
> of such patients and brought them into effective care processes.
>
>
> We have collected 100,000+ blood samples for genomic analysis to be
> correlated with EHR records regarding, e.g., age, gender, problem list, and
> response to various drugs.
>
>
> If I'm talking past your question, please let me know
>
>
> Best regards.
>
>
> Jim
>
> James M. Walker, MD, FACP
> Chief Medical Information Officer
> Geisinger Health System
>
> The best way to predict the future is to invent it.
> - Alan Kay
>>>> "[log in to unmask]" 11/05/11 10:13 AM >>>
> Dear Jim and Marguerite,
>
> Could you elaborate on this? Easy would be awesome but effective with
> benefits is even better! My imagination has been sparked by all this and
> although it could be an IT nightmare at this point maybe it is an
> information goldmine. Banks etc mine data relentlessly for their own ends to
> good advantage, it makes sense to Find ways this data could be useful to
> progress science and help people
>
> Amy
>
> Amy Price PhD
> Empower 2 Go
> Building Brain Potential
> Http://empower2go.com
> Sent from my iPad
>
> On 5 Nov 2011, at 09:57, Jim Walker wrote:
>
>> Thanks, Marguerite.
>> It is very far from easy, but you and we do it all the time with
>> considerable benefits.
>> Jim
>>
>> James M. Walker, MD, FACP
>> Chief Medical Information Officer
>> Geisinger Health System
>>
>> The best way to predict the future is to invent it.
>> - Alan Kay
>>>>> Marguerite Koster 11/04/11 4:29 PM >>>
>> Hi -
>>
>> Kaiser's decision to remove Vioxx from its regional formularies occurred
>>
>> before the implementation of the organization's EMR. I should add that
>> EMR's are still in their infancy, and usually built as clinical
>> management
>> systems, rather than systems for robust data extraction and analysis.
>> People sometimes have the notion that extracting data from an EMR is an
>> easy process. Far from it, though, especially if you want a clean and
>> accurate dataset. There are also issues with data that is only
>> available
>> from EMRs in text format.
>>
>> Marguerite
>>
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>>
>>
>>
>> "Djulbegovic, Benjamin"
>> Sent by: "Evidence based health (EBH)"
>>
>
>
>
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