Thursday, July 21, 2011

Opinions on Public Health

Keith discusses his views on Public Health in his (somewhat long) blog post. First things first - what is the role of public health (also referred to as population health)?

My thoughts - to analyze, record and improve the health of the population as a whole by collecting data about individuals, researching trends across populations and appropriating and distributing best practices and care for individuals.

A few observations:
I didn't use the word patient, but instead "individuals". This is because the population consists of both patients as well as non-patients.
Data is collected per individual but the analysis and research should be across a defined population.
Finally, to complete the circle to improve the health of the population, feeding best practices back into individual cases (patients and non-patients). Care can be delivered and best practices adopted only if this happens at the level of the individual.

So, in some sense, I see public health starting off by dealing with the patient level, moving to the population level and then coming back down to the patient level. Here is a little illustration to help:

 
I've already discussed some of the challenges of the political and jurisdictional nature here.

There are some technical challenges that we need to overcome in order to architect a sensible solution for automating data collection in public health. Some of these have to do with standards that are currently being worked on in HL7 as well as profiles being written in IHE. Are we there yet from a technical perspective? Absolutely not. However, we are a LOT further along compared to the challenges faced operationally and politically. Power and Money drive too much in this country. Right now, nobody wants to cooperate unless there is some form of profit associated - or at the minimum, no loss of one's powers and jurisdiction.

I was fortunate to have an interesting discussion with a couple of other people at IHE - MW, LF and NK at lunch today about the challenges in applying automating solutions to the public health areas.

This, like a lot of things, is a situation of "Catch 22" or a cycle where it is difficult to get the first step going. Since the states own public health data, and the center needs to purchase it from them, the states want incentives to conform to any standards developed by the center. Vendors obviously want one set of standards across the country while the different states have no incentives to agree upon one standard set of data or workflows. In fact, I will go on to say that I don't think that in public health, there is even an agreed upon workflow to collect the necessary individual data and what to do with it.

So, there are several challenges, and how do we move forward? First, we need to establish common workflows and data requirements. Next, we need to create standards while engaging both vendors and experts from areas of patient care, non-patient information collection as well as public health. Then, maybe create a new standard? Okay, let's rephrase that to agree upon a single standard for each of the different domains withing public health. It is important to try to standardize the workflow too. Finally, getting the buy-in from the states to require the use of these standards.

At the lunch table, we discussed how it would help to have a pilot first. The pilot should be one or two states with a handful of hospitals / provider organizations. It is important to restrict the participation to a handful of hospitals and provider organizations to allow for standards and profiles to mature before expanding the pilot for general consumption. This would also give the opportunity to demonstrate the possible savings from the pilot sites.

RPE and XDW

IHE's ITI and QRPH committees today met again to discuss the similarities and differences between RPE and XDW. I'll start first by giving a quick overview of what each profile is and then discuss my viewpoints on the comparison.

RPE - Retrieve Process for Execution
RPE was a profile that was written a few years ago and at the time was called Retrieve Protocol for Execution where protocol referred to research protocols. The purpose originally was for a protocol executor to retrieve a protocol from the protocol definition manager and execute it while providing updates to a state manager. RPE has evolved since then. Now, The process executor and the process state manager both retrieve the process from the process definition manager and the executor then retrieves executable steps from the process state manager and executes them, finally providing updates to the state manager.

XDW - Cross-enterprise Document Workflow
XDW is a profile where the the XDW content updater consumes a workflow document, performs some workflow steps and replaces the document with an updated workflow document.

When comparing these two profiles, it is very easy to make arguments for both the similarities as well as the differences between them. Some are highlighted below:
Similarities:
Both profiles deal with some type of process or workflow.
Both profiles allow for shared execution of a process or workflow.
Differences:
RPE has more of a central execution architecture while XDW has more of a distributed execution architecture.
RPE attempts to automate the execution steps with executable tasks while XDW does not.
XDW documents the workflow steps that were completed in a document architecture while RPE does not.

Once again, I will argue that several other similarities and differences can easily be documented. So, what is the purpose of having these two separate profiles.

When posed with a problem that could be potentially solved by either of these profiles (or a combination of both), how does one figure out what the best solution is. This is somewhat of an architectural question and some level or art comes into play. However, both ITI and QRPH have agreed to create a decision tree that will help answer this question based on collecting more information about the problem. I will refrain from posting further thoughts till we have some semblance of a finished product from the two committees.

Proliferation of Standards

For those who have worked with standards enough, this one might hit home a little bit. It is from xkcd.com






Nails it...