The Networked Health Enterprise

Abstract

Informatics and information technology hold the promise of a consumer-centered health enterprise—one that provides quality care at a cost society is willing to pay; one where need-based, adaptive, competency-based learning results in cost-effectiveness of health education; one where team-based health and learning on demand, coupled with monitoring of process outcomes and network access to expertise, guarantee quality. The barriers to this promise are the professional guilds, the cross-subsidies that support the health enterprise of 1998, and the lack of respect for privacy. Collectively, the informatics community needs to develop a compelling vision that will galvanize the health community to action. If the health community does not step up to this challenge, consumers will take advantage of disintermediation. Empowered by the network, they will go outside the system into hands that meet their needs.

Informatics has the potential to support a revolutionary improvement in the health infrastructure. I begin this paper by depicting one vision of how people, providers, and information could come together to produce health. The scenario centers on the consumer. It represents an ideal goal, but it is theoretically achievable in a decade. The challenge is that this vision threatens the roles and mechanisms of support of the stakeholders in the current health enterprise. Next, I outline a model for a networked health enterprise, one that could support the vision and be sustained under the rules of the emerging network economy.¹ This model centers on the work force—how people learn, are certified, and come together to provide a health enterprise. If we can envision a way to make things significantly better for consumers and efficiently provide a more effective work force, entrepreneurial business minds should be able to work out a transition plan for re-inventing the guilds and dismantling the cross-subsidies.

This vision statement is not a prediction. First, a thoughtful prediction must grow out of an evaluation of changes that are under way today. Anything else would be merely a guess. Truly revolutionary changes come where they are not expected. The most important part of the future will therefore be missing from a thoughtful prediction. Second, predictions are part of a reactive process. They help you prepare for a change that is happening around you. Although such preparation is an important survival skill, it does not have the same impact as the forces that are causing the change in the first place.

A Vision of People, Providers, and Information Interacting to Produce Health

I see a world in which people learn about health issues during the kindergarten through 12th-grade years, exploring the biomedical literature and research databases with the aid of a digital teacher that adapts to their levels of understanding.

Trends in height, weight, vital signs, nutritional status, expenditures, and interventions are monitored noninvasively by devices ranging from transmitters in weighing scales to the home inventory management system and records from restaurants, medication- and supply-dispensing boxes, and such. People review these findings, together with the implications of their genetic profile and habits, and model various health maintenance options to find the ones that fit their goals.

Data about the environment and data from public health surveillance are monitored according to each person's health profile. People with respiratory problems are alerted to changes in air quality, for example, and pregnant women are notified of a developing measles epidemic.

I see a world in which the primary health provider plays the role of mentor and coach. Health is viewed holistically, recognizing the interplay among family, education, finances, the brain, and pathophysiology. Simple questions are answered electronically. At the annual checkup, the provider and the consumer review the health logs, the record of use and understanding of information resources, and model alternative lifestyle and disease management strategies for the next year. Other primary providers administer services such as physical therapy or respiratory care.

Medications and health-related supplies are requested electronically. As appropriate, the request is filled as needed after review by the primary health provider, by a disease management specialist, or by an expert in the area of the supply (e.g., pharmacology or orthopedics). Data about fills, refills, and change in status support health management and evaluations of safety and efficacy.

I see a world in which diagnostic problems are researched by patients and their primary health providers with the help of a digital consultant. Synchronous and asynchronous expert help is available as needed over the network.

Each health-related invasive procedure is managed through remote robotics by a small cadre of experts who are dedicated to that activity. Every case is monitored for markers of process quality.

A Model of a Networked Health Enterprise to Support the Vision

Need-based, Adaptive, Competency-based Learning

Students will enter the health professions through a single learning pathway and then differentiate depending on the services they wish to provide. Learning and employment will be closely coupled from the start. Early in the process, learning will predominate.

Employment will be part-time and at a level comparable to an emergency medical technician. At this juncture, employment will provide real problems to stimulate fact finding, a way for the learner to know whether they enjoy the work, a means of demonstrating competency, and some income. The types of jobs that are available will increase as the learner adds competencies to their portfolio of skills. At each step, the learner will have a basis for deciding whether to work at the level that they have attained or seek additional skills. As they level off, the balance of effort will shift toward employment from learning, but the habits will have been formed to support lifelong learning in the workplace.

Entry Phase

The student is eligible after completing the equivalent of high school and begins with a six-month to two-year adaptive program. In this entry phase, they acquire or demonstrate competency in problem solving, interpersonal communication, scientific vocabulary, system function in health and disease, and information search and filtering strategies. Students with prior experience or advanced education are able to complete the entry phase through a network-based national program, for a nominal administrative fee plus copyright fees associated with accessing instructional modules, expert lectures, or information resources. Students who need more assistance enroll in a networked learning community or full-time course, paying additional tuition to cover the greater expense of that service.

Basic Practica

After successfully completing the entry phase, the student selects an initial career path and enrolls in a competency-based learning practica. The practica phase usually requires six months to two years, depending on the nature of the career and the breadth of services the student wants to provide. Pathways include assisting in health maintenance or care; in diagnosis, treatment planning, or procedures; and in research. The practica takes place in a community setting and consists of one or more rotations. Case logs, use of instructional modules and information resources, and evidence of understanding are tracked in a database. A practica is complete when the requisite experience and competency have been documented. Detailed review of the transaction logs of individual cases are used to monitor the effectiveness of the process. The student pays a nominal administrative fee during the practica. Fees for accessing instructional modules and information resources are paid as an expense of the practice in lieu of salary.

Advanced Experience

Individuals who want to become experts in an area of health services or to design research projects go on to enroll in a two-year basic science program. As in the entry phase, some students complete the basic science phase through a network-based national program, while others enroll in a networked learning community or a full-time course or school, and their tuition depends on the level of support they require. The clinical expert track requires advanced two- to five-year clinical practica at a tertiary-care facility. The research track requires a three- to five-year research associateship. The trainee receives a modest stipend from their mentor's practice or research support during these advanced experiences.

Team-based Health and Learning on Demand

Primary Health Providers

The primary health provider coaches consumers as they access information about their concerns over the network, model their choices, and track their progress. Prevention and care are managed according to pathways developed by primary health providers and their advanced expert partners. Variance analysis and computer-based health records provide feedback on the provider's efficiency and effectiveness. Digital assistants sound an alert when a decision may result in problems. Synchronous or asynchronous expert advice is available over the network. An individualized weekly curriculum is prepared for a half day of learning for the provider, based on new information in their area, their case pattern, and areas of misunderstanding indicated by their alerts. At any time, they may complete additional practica in order to receive credentials in new areas. If they do not keep up with their curricula, or if their outcomes fall below benchmark without explanation, a refresher is required. Primary health providers also serve as a first-tier mentors for students in basic practica in their areas of practice. They recruit patients for health services research and participate in trials managed by their advanced expert partners.

Advanced Experts

After the advanced practica, the clinical advanced expert is supported by the same information and communication infrastructure that supports the primary health provider. The two practitioners work in partnership to develop pathways and conduct health services research. They use remote visioning and robotics to provide consultation and procedure backup around the world. They develop instructional modules for use by consumers and providers.

Benefits and Challenge of Revolutionary Change

A health system built on this type of revolutionary change would be much more effective and efficient than the health enterprise of 1998. Individual consumers would be in charge, engaged in their own health maintenance, and informed. Duplication and competition between health disciplines would be eliminated as competency became the sole credential for providing services. The makeup of the work force would adapt rapidly to changes in needs. The learner would get just what was needed and from the best source. There would be a marked reduction in the debt burden for the primary health provider. Learning would be built directly into practice, and portfolio careers would be supported. Experience and performance would be used to monitor competency. Extended science training would be concentrated where it was most needed. A lifelong interaction would be created between the learner and their learning infrastructure. The advanced expert would be allowed to practice worldwide in a focused area. Mentors would have a global market.

This vision requires a robust information technology infrastructure and advances through informatics research to support security, intuitive human interfaces, connectivity, data aggregation, and simulation or modeling. I am confident that technology building blocks for the infrastructure to support the vision are within reach.

Three obstacles stand in the way of overcoming the status quo to take advantage of the infrastructure. First, the health enterprise of 1998 is built on professional guilds. Each defines a body of required knowledge and a curriculum for imparting it. This organization worked well when facts were few and new information rare. As information has exploded, curricula have expanded, education has become more expensive and less sufficient, and the guilds have become overlapping and competing. The guilds are becoming a barrier to an effective health system instead of the means to such a system. Information technology and informatics can transform the information explosion from a problem into a rich resource, but only if the guilds will give up their hold. They need to re-invent themselves in a way that will guarantee quality within the networked enterprise.

Second, the health enterprise of 1998 is supported by a web of cross-subsidies. For example, students pay tuition, which is covered by debt, which is repaid later through practice income. Faculty time is contributed because faculty receive adequate income from their clinical activities. This model worked well when the teachers provided the manpower for charity cases and there were few other expenses. With demand for universal access to high-technology medicine and with cost plus reimbursement by Medicare and Medicaid, there were no incentives to control cost. Tuition and education-related debt increased, and the efficiency and quality of teaching were not controlled because it was not a “paid” activity.

This spiral is not sustainable in the face of reductions in clinical revenue. Information technology and informatics can eliminate much of the cost of education if faculty will give up the pretense that teaching involves passing knowledge directly. The best teachers challenge students to find what they need on their own. The costs associated with time for expert mentoring, linking material that can best impart a competency or creating original instructional content, could be afforded as direct expenses of education.

Third, the health enterprise of 1998 treats information as belonging to the enterprise. This idea developed when patient records were memory resources for the patient's physician and interactions were direct between patient and provider. With the fragmentation of the health system, and the use of information for administrative purposes, violations of privacy became normal. Examples range from questions asked in a public waiting area, to conversation about patient problems in the elevators, loose management of charts, and use of patient data for development and promotional activities. Information technology and informatics can provide for secure data storage and limit access to a need-to-know basis, but these will not translate to patient privacy without a mindset change within the health enterprise. Health-related workers need to demonstrate respect for privacy in every act. They need to be taught that respect for privacy is the key to obtaining and using data about the patient, which is in turn the key to an efficient and effective health enterprise. Such a statement may become the Hippocratic Oath of health in the information age.

Conclusion

The health enterprise of 2008 is unlikely to be exactly like the informatics-enabled model that I envision. The barriers presented by the guilds, the system of cross-subsidies, and disregard for privacy may be too great. However, it will be as unlike the enterprise of 1998 as is the enterprise outlined in the model.

Collectively, the informatics community needs to develop a compelling vision that will galvanize the health community to action. If we do not step up to this challenge, consumers will take advantage of disintermediation. Empowered by the network, they will go outside of the system into hands that meet their needs.