Other Voices: Dr. Russell Maulitz Shares His Thoughts about the Intersection of Medical Informatics and Knowledge Services

 

During the last year I’ve had the good fortune to get to know Dr. Russell Maulitz.

In that time, I’ve learned that he is impressively knowledgeable about KM and knowledge services. I learned that quickly, for in our first meeting, during the usual “how-do-you-do?” and “what-do-you-do?” of the opening conversation, he asked about my work. I described my affiliation with our important new discipline. Without missing a beat, he said, “That’s good to know. I’m a knowledge manager, too.”

Russ – yes, we use first names, since we’re now friends – is Chief Medical Officer at Starship Health Technologies LLC and a professor in the Department of Family, Community, and Preventive Medicine at Drexel University’s College of Medicine in Philadelphia. As a physician he is board certified in internal medicine and his medical practice combines with his teaching and with his work with Starship to give him a particular perspective about what’s happening in the medical profession.

And as I’ve gotten to know Russ, what delights me is how he got there, through a fascinating juxtaposition of interests. For one thing, in much of his work as a younger man he focused on the history of his chosen field, including a long and rewarding period of time in Paris. He was successful in his studies, so much so that he became well known for such efforts as Grand Rounds: One Hundred Years of Internal Medicine, written with Diana E. Long (Philadelphia: University of Pennsylvania Press, 1988). About the same time his Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century (Cambridge University Press, 1987) was published, providing what the publisher describes as “a detailed account of the rise of pathological anatomy in France and England.” It didn’t stop there, though, for in the same book Russ took the story further, detailing “the efforts of Thomas Hodgkin, Robert Carswell, and others to import the new science of pathology to Great Britain.”

So how did the knowledge services connection kick in? That started during these same years when Russ was working with medical history, when he began to sense that the management of medical information and access to that information by the people who needed it was too important to ignore. With the rise of information management (the first of those converging elements in our definition of knowledge services, and including information technology), Russ found himself as the principle investigator for a project to digitize the Index-Catalogue of the Library of the Surgeon-General’s Office (Index-Catalogue). A collaborative project conceived by the American Association for the History of Medicine (AAHM) through its ad hoc Committee on Electronic Media (COEM), chaired by Russ, the pilot project was supported by the Wellcome Trust and the Burroughs Wellcome Fund. The National Library of Medicine (NLM) funded the digitization phase and the digitized product – IndexCat™ – is hosted by NLM at its Web site: http://indexcat.nlm.nih.gov. With almost four million entries digitized, this resource allows researchers to search across all five series of this remarkable overview of medicine’s early history through its literature.

The driver for the project – even in those early days – matches closely just about everything else Russ now speaks about when he talks about his work, for he moves quickly into the topic of knowledge sharing. At Drexel he was responsible for organizing the first community based knowledge resource for medical students. Through this effort it soon became clear that point-of-care access to medical information was going to play an ever-growing and critical role in healthcare. And at about that time (1995), Russ began to connect with the larger subject of medical informatics, a connection that (even though he probably wasn’t thinking of it this way) matches what we talk about when we deal with knowledge services, converging – as noted above – information management with knowledge management and strategic learning.

Medical Informatics. Russ describes medical informatics as “the science of health care technology, bringing together information science and technology,” a good definition he builds on in a taped interview for a business channel in Philadelphia. You can view the interview here, where at about 3.45 minutes into the interview Russ provides his own working definition about medical informatics: “the informaticist is going to do the information science, and informatics is really where computer science and healthcare and information science come together and overlap. Information is the science and health IT is the technology, including getting down into the weeds and rolling out electronic health records and all of the technological realities of the modern world.”

So if knowledge services is all about the practical side of developing, sharing, and using knowledge – that end-product we like to characterize with the KD/KS/KU acronym – it’s not so hard to connect medical informatics and knowledge services, is it?

“Not at all,” Russ says. And he talks about how when he first became interested in the larger subject of medical informatics, that practical side was more “aspirational” (as he puts it) since at that time medical informatics had a way to go. (As indeed, he insists, it still does.) Yet with this aspirational focus medical informatics evolved into a reach for something better than just technology, something that – in this case – would benefit the larger society and contribute to the greater good.

That was exactly what Russ and his colleagues in the medical profession were dealing with: “Being a clinician shows me where the pain points are when it comes to knowledge sharing,” a situation Russ characterizes as one of the “sweet problems” that influence his approach to his work.

Why so?

Because of two major influences he identifies, both leading to the development of higher quality information management as medical informatics became a more sophisticated or, we might say, more “polished” branch of computer science and information science.

Patient Engagement. The first of these major influences, Russ notes, “came about because we saw a scaling up of the electronic health record (EHR), scaled so far up that in recent years we’ve seen an 8-fold increase in the number of electronic health records.” Since much of Russ’s work has been – especially recently – in R&D in health care technologies, particularly with respect to mhealth (mobile health) and clinical communication training, he is particularly interested in how this “scaling up” in EHRs has led to changes in patient engagement.

“Where’s the patient?” he asks. “It’s been one of our questions all along, to figure out how we could put the patient back at the center of the relationship with the health care professional.”

There have been attempts, with varying levels of success, Russ notes, but, sadly, there’s no clear business model yet. Yet we are seeing – and have been seeing for a few years – such efforts as the growing popularity of the patient portal in place in many health care facilities

[Author’s aside: even in my own relationship with my primary care physician I’m amazed at how much information I can find about my own medical care in my own facility’s patient portal system. And I’m reminded of a story back in earlier days when I was dealing with knowledge services, a story I used in a presentation based a June 16, 2008 article from Time in which Kathleen Kingsbury described a flagship product – MyChart – at Cleveland Clinic designed to “enable patients to access their own EHRs and find up-to-date medical research.” A precursor, perhaps, of today’s patient portal.]

Still, “we’re not there yet,” Russ says, “and since there is no clear business model, it’s mostly been the vendors and content managers carrying along much of the activity. But we’re getting closer, and as we move toward more browser-based frameworks and similar solutions, we’ll see more success in this.”

Part of that success will deal with incentivizing physicians to share, Russ notes, in order to coordinate care. It was a point made in the Time story noted above, when Kingsbury wrote that leaders at the Cleveland Clinic were clearly aware that convincing the medical staff plays an important role in moving toward higher levels of patient engagement: “We had to prove that this effort was going to make their – the physicians’ – jobs easier not harder,” Kingsbury quotes the clinic’s innovators as saying.

The Health Technology / Government Connection. So there is movement toward solving Russ’s sweet problem of knowledge sharing, and in the past few years (and for some time to come) its success will connect with that second influence he identifies. It’s what he characterizes as the “sudden change in the connection between health information technology and role of the federal government in sponsoring support for better health information technology.” This activity, Russ asserts, is so important that it’s been what he calls a “mass-action effect,” totally changing the environment with respect to EHRs and medical informatics. It’s an effect he describes as “like an asteroid hitting the earth.”

Talked about for a long time, particularly by certain politicians and leaders in the medical profession and some of the professional organizations working with the medical profession, the Health Information Technology for Economic and Clinical Health Act (abbreviated HITECH Act), was enacted under Title XIII of the American Recovery and Reinvestment Act of 2009 (Pub.L. 111–5). It’s a seriously intriguing story, and all clearly documented in a provocative Washington Post article from 2009 (The Machinery Behind Health-Care Reform by Robert O’Harrow Jr., which Russ pointed me to. And – not to put too fine a point on it – since I am so interested in background stories about how things happen in knowledge services, it’s an article I highly recommend for knowledge strategists in – or moving into – the health care KM/knowledge services field. O’Harrow clearly outlines – as Russ puts it – how that information technology asteroid “hit the health IT planet.”

A couple of up-front quotes from the article are worth mentioning, the first having to do with one of those professional organizations I mentioned, the Healthcare Information and Management Systems Society which, according to O’Harrow, “had worked closely with technology vendors, researchers, and other allies in a sophisticated, decade-long campaign to share public opinion and win over Washington’s political machinery.”

O’Harrow continues with his description of the group’s work:

With financial backing from the industry, they started advocacy groups, generated research to show the potential for massive savings, and met routinely with lawmakers and other government officials. Their proposals made little headway in Congress, in part because of the complexity of the issues and questions about whether the technology and federal subsidies would work as billed.

Surprisingly, with the financial downturn of 2008-2009, these high-quality health care advocates found themselves able to move forward for, as O’Harrow describes it, the crisis “created a remarkable opening for a political and financial windfall: the enactment of a sweeping new policy with no bureaucratic delays and virtually no public debate about an initiative aimed at transforming a sector that accounts for more than a sixth of the American economy.”

So it worked, and under the HITECH Act, the U.S. Department of Health and Human Services is spending an estimated $25.9 billion to promote and expand the adoption of health information technology (O’Harrow’s article referred to “$36.5 billion in spending to create a nationwide network of electronic health records”).

And it was all happening before the Affordable Care Act came on the scene (but not much, and surely – although I’m not expert – there is plenty of synergy between the benefits of the HITECH Act and ACA).

Is there any wonder why Russ refers to what’s happening with EHRs and information technology as being “like an asteroid hitting the earth”?

Where We’re Going. From where I sit, I see it all coming together in the work that Russ and his colleagues are doing at Starship Health Technologies (and at many other companies as well – this is a wide-open field). I mentioned earlier that one focus of Russ’s work is clinical communication, and training in clinical communication. It’s work that is given serious attention at Starship and it’s a focus that brings us back to the bigger picture of knowledge sharing, whether in the medical profession or in any other discipline.

Russ believes this could be our biggest challenge:

“Person-to-person communication – between patient and provider and between and among providers – is the foundation of health care efficacy and patient empowerment,” he told me, and he went on to describe the particular situation in health care with a statement the people at Starship use in their approach with their clients:

…clinical communication is often ineffective, yet providers receive only minimal education or training in this critical skill. In the accountable future, clinical communication will need to be more timely, more effective, and fully frictionless. The communication skills of providers will have to adapt to an increasingly diverse patient population and the demands of enhanced collaboration and care coordination.

“Will we get there?” I asked Russ.

He didn’t respond directly but he did lead me into further discussion – a fruitful discussion between the two of us – about how those of us working in KM and knowledge services might begin to think about the value of communication, regardless of the subject specialty we’re in or the institutional or corporate environment in which we’re employed.

It certainly makes me wonder: perhaps all we need to do is to review how – and why – we communicate. Then knowledge sharing will just be part of what we do.