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Why should the future be told in a different language
- 1. Open Seminar Wonca – Université Claude Bernard Lyon 1 Lyon 31/08/2017 Risk management and classification: Why should the future be told in a different language? Philippe AMELINE philippe@ameline.net / @p_ameline
- 2. The issue 1) create dedicated codes In order to enter the risk management universe, is it better to... à la “risk of cardiovascular disease” ...or to... 2) use existing codes in a new dedicated structure slot Episode of Risk of “cardiovascular disease”
- 3. What did we learn with the Ligne de Vie ? Hence, when telling Mrs Smith’s “health journey”, creating dedicated “risk of” codes obviously would mean that all diseases codes are to be duplicated! Tell and organize a patient health journey: - 55000 terms ontology (the words) - documents as trees (the (dependancy) grammar)
- 4. ... Risk management open the way to a new paradigm - “now” takes place on the middle of the screen - risk targets are shared in the patient frame The good old “patient record” becomes a Health Project Manager
- 5. From SOAP to (PRA)SO If a ? remains, the document can be shared with other health team members as a “virtual staff”. From local to team work
- 6. New paradigms of care Cohen, J (21st Century Challenges for Medical Education; 9th International Medical Workforce Conference; Melbourne, Australia; November 2005) The individual → The community Acute disease dominates → More chronic illness /disability Episodic care → Continuous care Cure of disease → Preservation of health Reactive → Prospective Physician provider → Teams of providers Paternalism → Partnership with patients Provider centred → Patient / family centred Parochial health threats → Global health threats
- 7. Conclusion There is little reason to create dedicated codes except if trying to insert an ersatz of risk management inside (current / old style) information systems. Risk management is a real evolutionary path both for medicine and health information systems. Telling the future in a different language is a good way to get stuck in the old paradigm. Risk management has a larger scope than usually thought, for example drug interaction is RM.
Notes de l'éditeur
- When dealing with risk, I have witnessed that the usual behavior is to create a set of specific codes (or terminology entries, or ontology concepts, etc) à la “risk of cardiovascular disease”, as if risk management was a separate “module” (in the way drug management and lab results are so often treated as separate components with their own internal languages, say ATC and LOINC). The alternative is to keep using the codes usually allocated for diseases and create a new structure element for risk like it is usually done for describing a processes the episodes of these diseases. We will discuss the two options from a nearly twenty years hindsight with the Ligne de Vie project.
- The Ligne de Vie has been created (mainly inside the Cisp Club) to tell and organize the health journey of individuals. Here, an acute pancreatitis led to a diabetes later treated by insulin. To tell this narrative, all documents (notes, reports… including demographics) are trees filled with elements form a 55,000 terms ontology... in the same way an English sentence is a grammar tree filled with words from the English vocabulary. In 2003 we started working on risk management for cancer with a group of family practitioners whose main asset is a “dictionary of consultation results”. They immediately added “risk of...” entries for the 8 cancers at stake (mouth, cervix, breast...) in their dictionary to the existing 270 entries. When I realized that duplicating each disease concept would lead me to add and maintain thousands of entries in the Ligne de Vie ontology, I decided to instead create a dedicated structure. I now realize how deeply this initial decision made both partners of this project radically part.
- Implementing risk management in the Ligne de Vie as a “virgin land to explore” allowed us to discover 3 main things: 1) Medical records are fully dedicated to the patient history while risk management is entirely future oriented. The “now” cursor moved accordingly from the right side to the middle of the screen. 2) Medical records operate in the practitioner’s reference frame while risk must be managed in the patient’s reference frame. For example, would the patient’s weight to be measured every day, this target has no place to be in doctor’s workflow when this practitioner only sees the patient once every month. 3) Medical records are local tools while risk management is by nature project oriented since its processes must be shared by a team (at least the patient and her GP). You can easily guess that the conceptual distance between us and the group of GPs who managed risk as “yet another consultation result greatly increased with each step.
- Let’s go further and imagine a patient encounter user interface that fits with such concepts. The “now” separator line “slides open” to display a “cognitive map” that separate the previous processes on the left and the next ones on the right side. Reasons for encounters and clinical observations are recorded on the cognitive map. Here, a set of symptoms and observations lead the practitioner to think that a new problem is arising and/or that the treatment must be adapted. He added two question marks on the right side. If some ‘?’ remain unlabeled (unanswered) when the encounter ends, then the practitioner can share this cognitive map with other members of the patient team and use group decision tools (like the Question, Options, Criteria (QOC) graph) to adapt the project. One of the most precious achievement of such maps is to keep an history of decision making (at least to answer the usual question “why in hell did they prescribe/stop this?” in a way that can allow to smartly compare the previous context with current situation).
- Jordan J Cohen was the president of the US Association of Medical Colleges when he published this list of new paradigms of care. Ten years later, we can assess that the medical domain is still stuck in the same old paradigm, delineated on the left… and I would say that medical information systems are not fit – by far - to make the transition easier. In many countries the electronic health record mainly evolves as a surveillance system, usually motivated by pay for performance (P2P) considerations. Risk management may be the proper incentive to have practitioners set out. Not embracing change, and keeping software whose decision support role marginally evolved since 1980, could lead medical doctors to deadly miss two major turns: the switch from acute care to chronic follow up and the global evolution toward the information society.
- John Hagel is an author whose inspiring book “The Power of Pull” subtitles “How small moves, smartly made, can set big things in motion.” I believe, from what I experienced with the Ligne de Vie that embracing risk management can be such small move to pull practitioners out of their (deadly) comfort zone toward Cohen’s paradigm shift. Unfortunately, there is an other side to this coin, and small resistance to change, for example by packaging new concepts so that they can fit in old information systems, can quickly lead to obsolescence.. Don’t try to fold the future into the old way. Embrace change and use risk management as an opportunity to become the managers of your patients’ health projects… before modern information systems enable other people to enter the cast for this role