“Know the enemy and know yourself, and your victory will never be endangered; know the weather and know the ground, and your victory will then be complete.”

 Sun Tzu 500 B.C.

Twenty-five hundred years ago, Sun Tzu asserted that with sufficient knowledge about yourself, your opponent and the environment, your victory would be assured. In our battles against rising health care costs and medical errors, this wisdom has been lost.

As an industry, when it comes to technology we are concerned with adoption, usability, efficiency and features. We are much less concerned with knowledge generation. Unfortunately, it is the knowledge generation that will lead to a significant return on investment. Technology purchases that do not help us understand our organizations, staff, environments and patient care challenges will never demonstrate the promised gains in safety and cost reductions.

The disappointing performance of electronic health records has been demonstrated in several studies. Health Affairs published an article in 2010 showing only modest--and often clinically insignificant--gains in efficiency and quality with the adoption of EHRs. A 2011 article in Archives of Internal Medicine did not show consistent association between EHRs and clinical decision support (CDS) and improved quality in ambulatory care settings.Tailored CDS tools have had slightly better results as demonstrated by a randomized trial that showed modest improvements in asthma care, according to a 2010 Pediatrics article. The Annals of Family Medicine published similar findings with regard to adult diabetes care in 2011.

Despite this discouraging evidence, significant and measurable safety, quality and fiscal gains are achievable if we begin to utilize technology to generate actionable knowledge. Recently, the Geisinger Health Plan reported that telemonitoring of patients after discharge and active interventions by case managers reduced readmissions by 44 percent for patients with congestive heart failure, diabetes and hypertension. Their program used an interactive voice response system to generate knowledge of the patient’s clinical condition after discharge and communicate clinical deterioration to case managers with the ability to initiate an intervention.

In my own work, I have led the design of a knowledge-based clinical decision support system for nosocomial blood clots. The utilization of this system led to a sustained 25 percent reduction in nosocomial blood clots as well as substantial cost savings. Additionally, the use of data analytics to understand care delivery processes in sepsis led to the discovery of a delay in antibiotic administration and a key intervention to correct this. Process changes that help correct this delay immediately led to a greater than 30 percent reduction in mortality from sepsis as well as significant cost savings.

As these examples demonstrate, knowledge- not technology- is the key to substantial gains in clinical care. Sun Tzu’s ancient wisdom that knowledge is the key to victory still rings true today. This wisdom needs to become a guiding principal for the HIT community, if we want to see returns on our technology investments and fulfill the promise of higher quality care at reduced costs.

John Showalter, M.D., is a board certified internal medicine physician and is currently the chief medical information officer at the University of Mississippi Medical Center. He also holds a Masters of Information Systems (MSIS) from Penn State University. John's interests include quality improvement and intelligent use of technology; he also blogs about innovating health care through clinical knowledge management at CKM Beat.



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