JUN 2, 2014 5:23pm ET

Triage: Kurt Vonnegut’s Advice for HIT Executives

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It's graduation time again for the nation's high schools and colleges, and every once in a while some radio station will dust off the old "Everybody's Free to Wear Sunscreen" speech, the sage words of life advice presented by somebody assumed to be Kurt Vonnegut at a college commencement.

It's not Vonnegut. The essay upon which the recording, done by film director Baz Luhrmann, is based was written by Chicago Tribune columnist Mary Schmich back in 1997. The Vonnegut connection is urban myth.

But Vonnegut, the Greatest Generation's Mark Twain, was indeed full of wisdom in other contexts. In Palm Sunday, his 1981 collection of essays and observations, he modifies the subject of triage from a medical to an academic context. Using his writing students from the University of Iowa creative writing program as the example, he said the top third of the class were those who were born writers, for whom anything as structured as a writing program, though it may have added some cachet to the resume, was probably superfluous. At the other end of the scale were those whom he termed "warm corpses," those whom no amount of instruction would help. Those in the middle third, he said, were those whom structure and teaching could help.

Vonnegut's triage, of course, was like triage stations set up in combat zones and natural disaster areas – hierarchical – in which victims of trauma were classified as those who could survive and those who could not, accordingly.

In terms of data management, it might also be ventured the healthcare industry is about to enter a time when executives need to begin thinking in terms of triage. After five years of intense effort around electronic medical records' adoption, industry veterans like John Halamka, M.D., John Moore of Chilmark Research, and John Loonsk, M.D., are calling for what may be termed agonizing reappraisal of where we stand with the goals of HIT in the U.S.

In fact, Loonsk's top recommendation is:

"Stop talking only about EHRs!- EHRs are part of a much bigger HIT ecosystem. They are like the leaves on a tree. There must also be branches, a trunk and roots. There are networks and hundreds of other HIT systems that support ancillary organizations and activities, population health and healthcare."

And that is where the concept of triage comes in for HIT. However, rather than thinking in terms of a hierarchy of the worthy and unworthy, the community HIT triage architecture might far more likely be a concentric concept, with core platforms like acute care records in the middle bull's eye, extended network architectures like record exchange with long-term care and rehab facilities and home monitoring devices in the immediate outer ring, and finally, community outreach technologies like needs assessments platforms, email lists, branded consumer apps, and communications efforts in the outermost ring.

These aren't all traditionally thought of as "health data." But clearly, if someone with as much experience as John Loonsk is urging the industry to expand the scope of its thinking, strategizing where each fits the larger mission probably can't start too soon.

In the past several weeks, I've spoken with executives and clinicians from several health systems that are just beginning to measure their community outreach – using the word "community" both in the sense of the health system internally as employer and externally as a regional presence – in ways beyond the strict constraints of EHR exchange and interoperability. Thus far, they don't have a lot of hard metrics, but there are some promising trends. For example:

* In Poughkeepsie, N.Y., after three-hospital Health Quest announced its Walkway Fitness Challenge, the system's web traffic went up 30 percent.

* In Charleston, S.C., the Medical University of South Carolina saw an 8 percent increase year-over-year in employee participation in Adventure Out, a month-long fitness program MUSC runs with the Charleston city parks.

* In Lebanon, N.H., participation in the employee wellness program run by the Dartmouth-Hitchcock health system went from 10.8 percent when the program had no financial incentive to 60.5 percent in 2011, after incentives (money deposited into employee health savings accounts) were offered. This year, the system added confirmed participation in a community sports league or activity such as a road race as an incentive.

Dartmouth-Hitchcock has also implemented a six-week online fitness challenge called HealthTrails as a part of its wellness program. Employees who meet activity and behavior modification goals where recommended receive funds for their health savings accounts (or as taxable cash in non-HSA accounts).

Robert McLellan, M.D., medical director of Dartmouth-Hitchcock's Live Well/Work Well effort, says HealthTrails is an example of how a health system can begin offering incentives and measuring their effect on employees.

"HealthTrails is an example of a social approach, and it's been highly successful," he says. "We can score participation through the data we're using from that, and we can also score, through a survey, kind of a mini-health risks assessment before and after, and we see change there."

In fact, he says, the internal efforts to offer new health-enhancing services could serve as incubators for wider initiatives.

"As an employer, the healthcare organization has many more opportunities to improve the health of a population than they do in the community in general," McLellan says, "and it saves them on the bottom line if they do it, which makes them more competitive. So I feel very strongly healthcare organizations should first get their own shop in order. Now there are lots of models out there to do that. And it gives organizations the tools to practice managing populations, which they are increasingly being asked to do."

Constructing data pathways that will enable more than lick-and-a-promise population health management is going to be a major undertaking. Rather than just digitizing what represents a small portion of any individual's life – his or her medical record – and ensuring it can be "meaningfully used," technologies with the combination of genomic, phonemic, social, behavioral, and environmental factors will have to be triaged and integrated in ways still unimagined. But such new knowledge, Vonnegut said in his novel Breakfast of Champions, is precious: "New knowledge is the most valuable commodity on earth. The more truth we have to work with, the richer we become."

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Blog Archive for Greg Goth

Triage: Kurt Vonnegut’s Advice for HIT Executives
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Physicians often have a rocky relationship with information technology.

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