Friday, June 1, 2012

High Velocity Medicine

Moving Toward High Velocity Medicine
From The Rock:
Where is the wisdom that we have lost in knowledge?
Where is the knowledge that we have lost in information?
-- T.S. Eliot, 1934
A while back I had a great conversation with Vi Shaffer and folks from Gartner. I've known Vi forever and find her to be a smart and insightful person who knows the field of health informatics quite well. We were talking about 'nanotechnology' for some background research I was doing for projects at Partners, and we got to talking about clinical decision support and knowledge management along the way. This conversation helped me crystallize one of the major issues I see confronting US healthcare delivery, and for that matter, healthcare delivery around the world: the need for High Velocity Medicine. Try this on for size:

 Many in the field have talk for years about the DIKW pyramid, which I think started simply as the DIK pyramid. In any case, the basic idea is that we live in a world of data about nearly everything -- especially as more and more of our lives are 'quantified', and the world is painted in a digital facsimile of itself (aka the Matrix!). Data are the objective facts about our existence, or for example: the height of Mt Everest in the graphic. Data may be compiled, however, to give us insights about things, or information. For example, the average height of mountains in Nepal, or a book about Mt Everest. When internalized, information becomes knowledge, or something we know first hand. But it is the last step, transforming knowledge into practice that is the true goal -- knowledge acted upon is wisdom. And with wisdom and experience, we need to know which data to look at again to complete the cycle, and create a virtuous learning system.

High Velocity Medicine jpg

Some have suggested that it may take as long as 25 years or more to covert new data into wisdom, e.g. to take a new clinical trial result and see it in routine clinical practice. In a seminal paper, Lau described in the NEJM in 1992 how long it took for thrombolytic therapy in acute MI to diffuse into routine practice -- the first clinical trial was performed in 1960, and thrombolytics in AMI became routine only in 1985. 

Given the appalling rate at which we routinely exercise our wisdom in daily life, or the practice of medicine, it is no surprise that this graphic is shaped like a pyramid -- perhaps implying less wisdom among us mortals, than knowledge, information, or data.

Yet, it is a central idea of biomedical informatics that we can improve upon this process of translation from data to wisdom, and apply it in the routine practice of medicine as wise, seasoned clinicians. We need to dramatically accelerate this translation of data to knowledge, and discern when is new knowledge 'true' and ready for general use, vs. that knowledge which is observed, and possibly even replicated, but perhaps not yet generally applicable.

To me, this suggests a new theory of evidence given the volume, speed, and diversity of sources of new data (aka 'big data') -- moving from hypothesis-driven clinical trials toward PheWAS (phenome-wide) and GWAS (genome-wide) association studies… with biologic plausibility and clear certainty assessments. But that's another topic.

With the explosion of biomedical data -- data on genotypes, phenotypes, social interactions, behavior, geospatial, populations, community, and more to come -- it is incumbent upon us to focus on the acceleration of this translation from data to wisdom, it's dissemination, and implementation in the tools of the day: electronic health records. I suggest this will lead to 'high velocity medicine': when we are agile with new data, compile it into information with routine ease, quickly understand and interpret it into new knowledge, and act upon it as wisdom with alacrity. This is the fuel for Berwick's "escape fire" - avoiding the current conflagration through the transformation and optimization of healthcare delivery, and the primary pursuit of health and wellness.

Discussion with Vi Schaffer of Gartner

Lau J, Antman EM, Jimenez-Silva J, et al. Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med 1992;327:248–54.
Berwick, D. Escape Fire: Lessons from the Future of Healthcare. 2002, The Commonwealth Fund.

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