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James L. Holly, M.D. |
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| James L. Holly,M.D. |
| February 06, 2003 |
| Your Life Your Health - The Examiner |
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(Editor's Note: On February 5, 2003, Dr. Holly addressed the Massachusetts Medical Society's Medical Informatics meeting in Boston Massachusetts. Today's article and the next two weeks installments of Your Life Your Health are excerpts from his address which was entitled: "Beyond Electronic Medical Records: The Hope and Promise of Electronic Patient Management." These excerpts will give The Examiner's readers an opportunity to see the efforts which are being made on a national stage to improve the quality of healthcare in America.)
Several years ago, I was browsing in a book store, and saw a book with a black fly leaf. I picked it up and it fell open to page thirteen. An interlinear jumped out at me, which stated: "Metanoia: -- A Shift of Mind." The paragraph went on to say, "(Metanoia is) the most accurate word in Western Culture to describe what happens in a learning organization&"
I knew the word metanoia and I knew that it had nothing to do with business. As a Christian and a Bible teacher, I have studied, written and taught that word for years. It is the Greek word for "repentance," and means to "have a change of mind or to change one's direction." I was absolutely confident that it had nothing to do with American business. In order to "debunk" what the author said, I read Peter Senge's The Fifth Discipline. Needless to say, "I had a change of mind."
I found in Dr. Senge's book a structural and philosophical foundation for what we were already doing at Southeast Texas Medical Associates in Beaumont, Texas. I also found another illustration of a principle a friend had taught me years before: the person who helps you the most is not one who teaches you something new, it is the person who teaches you how to say that which you already know or suspect.
Learning only distantly related to "taking in information"
Dr. Senge commented further: "To grasp the meaning of 'metanoia' is to grasp the deeper meaning of 'learning,' for learning also involves a fundamental shift or movement of mind&Learning has come to be synonymous with 'taking in information.'&Yet, taking in information is only distantly related to real learning."
If there is one thing which is needed in the medical informatics, or medical information technology world, it is a "change of mind." There needs to be a fundamental change of mind such that we are not talking about "electronic patient records (EMR)," but about "electronic patient management (EPM)."
Transitioning from an EMR mentality to an EPM goal is to apply Dr. Senge's concept of "generative learning" to the field of medicine. Addressing the concept of a "learning organization," Senge said:
"This then is the basic meaning of a learning organization& continually expanding its capacity to create its future. For such an organization, it is not enough merely to survive. 'Survival learning' or what is more often termed 'adaptive learning' is important -- indeed it is necessary. But for a learning organization, 'adaptive learning' must be joined by 'generative learning,' learning that enhances our capacity to create." (emphasis added)
If we continue simply to talk about electronic patient records, we may create a future in which we discover that we have only created a very expensive and very complex substitute for a relatively inexpensive transcription service. If we are going to impact the future of health care, we -- vendors, managers, providers, payers, institutions, every member of the health care team -- are going to have to begin thinking differently. This will involve at least three major shifts in our thinking. This will involve "Medical metanoia."
1. Those who are naturally competitors are going to have to work collaboratively. The reality is that whether we are in solo practice, in group practice or providing resources for health care providers in their practices, we are all part of a larger team, which, among others, consists of those we would call our "competitors."
It is a much larger team than those who are simply on our payrolls. This team consists of participants previously seen by health care providers as peripheral to the healthcare equation, such as pharmaceutical representatives, unit clerks, DME companies, home health agencies, hospital administrators, etc.
The dynamic interaction of all members of this community -- of this team -- is critical to the fundamental concept of electronic patient management. In this "new world," our focus must no longer only be on "my winning," because the reality is that if "I win" and if "they win," then "we all win."
If our only goal is to survive and to "triumph," we will not have changed our way of thinking and even if we succeed corporately, we probably will have failed in any thing which is ultimately valuable. This does not mean that we cease to compete, but it means that we now collaborate at some level with our competitors to make both of us better.
Recreationally, most Americans are drawn to zero-sum games -- football, basketball, car races, horse races, track and field, soccer -- in which there is a clear and decisive winner, by however narrow a margin, and where there is a clear and decisive loser, no matter how excellent a performance they turned in.
We're all charmed by Lance Armstrong's triumph over cancer and his four consecutive wins in the Tour De France. What I'm amazed at is that several people finished a ten-day race only 5 to 10 minutes behind him and experienced the "agony of defeat." In our "health care information" race, all finishers will be winners and because they drive the process, all participants will be winners, if they pursue the right goal. The best business model is not an "I win/you lose" zero-sum scenario.
2. Those who are naturally idealists are going to have to produce work which is practical. Americans are enamored with the fastest, the best, the biggest, the....you fill in the blank. None of these terms will apply to the successful electronic patient management tools which you will produce and use. Other words, such as "interactive," "connectivity," "stability," "efficient," etc, will define the parameters of our new pursuits. Our systems will have to be fast enough; they will have to be easy enough to use; they will have to be good enough, but superlatives will not apply. Once our systems are "fast enough," and "easy enough" to use, we can begin to focus on what is really important -- how do they help us increase the quality of care and decrease the cost of care which we delivery every day.
Yet, it is possible to design an elegant solution to healthcare's problems and not impact healthcare at all because it is not possible to use it within present day healthcare-delivery realities. One enterprising full-page ad in the New York Times heralded that "it is not how many good ideas you have that matters, but how many good ideas you can implement."
Forward thinkers versus Day Dreamers
Dr. Senge addresses the difference between a forward thinker and a day dreamer. He said:
"The juxtaposition of vision (what we want) and a clear picture of current reality (where we are relative to what we want) generates what we call 'creative tension': a force to bring them together, caused by the natural tendency of tension to seek resolution."
Senge goes on to discuss "personal mastery" which in its essence, he says, "is learning how to generate and sustain creative tension in our lives." Senge's discussion of "personal mastery" is beyond the scope of our current discussion but is worthy of everyone's review.
"Creative tension" can only produce results, however, when it finds a place from which to leverage change. Senge wisely comments that "Cynicism&often comes from frustrated idealism -- someone who made the mistake of converting his ideals into expectations." It is not enough to want things to change; you have to make things change. And, as IBM learned, when they encouraged "change agents" within their organization, "if you are going to change things, the change better make a difference."
Furthermore, medical informatics technology must provide us with tools not with toys. A tool makes your job more efficient and your product more excellent, while a toy only makes your job more amusing. Over twenty years ago, a physician in our community was using computers. He had one of the very first portable computers. He would visit his medical school and attend grand rounds, plugging into a medical database. When the question and answer time came, he would ask questions based on obscure publications which were on line but not available in the medical library. He was computer savvy and knowledgeable, but he used the computer as a toy. He never changed the process of healthcare and he never improved the care of his patients with technology.
3. Those who are naturally resistant to new ideas are going to have to become innovative and receptive to change. Here we confront the major economic stakeholders in the health care establishment. Change is suspect because it upsets the equilibrium, which, while it has not solved the systemic problems we face, it has kept our "opponents" in check. In order to succeed, we must all surrender some level of comfort and some level of control.
The innovation required to design a future which meets everyone's needs is a future fraught with discomfort, difficulties and uncertainty. None of these characteristics are pleasant to participants in healthcare, though they so well and so often describe the nature of our enterprise. Yet, change is the very nature of our business and if changing how medicine is practiced and/or how health care is delivered in America is not our goal, then we need to rethink what we are doing.
Innovators are going to have to lead the process of change by helping make those successful who are reluctant to change. Leadership is more often defined in dedication and demonstration than it is in dictation. Rather than dictating change, we are going to have to demonstrate the benefits of and the possibility of change with our dedication to change.
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