Health Outcome Infrastructure 1.2

Health Outcome Infrastructure - Paschane © 2010 Page 1

Health Outcome Infrastructure Initiative

David M. Paschane, Ph.D.

The Emerging Research Paradigm in Health IT

The paucity of coherent healthcare infrastructure may be the most significant risk to health, globally, and the reason for pursuing an Internet-based alternative. Rich and poor countries alike are demonstrating an enthusiasm for health IT solutions because it promises a leap forward in the long-standing delays in infrastructural development. The pursuit of Internet-enabled health IT may produce surprising results, such as rapidly matured healthcare infrastructure in middle-tier economies, where they face fewer of the entrenched institutional problems that hold back the high-tier economies. Nevertheless, these sudden changes come with risk—unwanted consequences in how the organization of medical services and patient information affects knowledge, control, and opportunities in the operations and experiences of healthcare. The purpose of the Health Outcome Infrastructure Initiative is to apply interdisciplinary sciences to representative examples of emerging IT-enabled healthcare infrastructure in various economic contexts, and use these maturing models to inspire commercial and government investors to expand and stabilize the healthcare infrastructures, domestically and abroad.

The Initiative has three complementary foci in researching emerging healthcare infrastructure and health IT. Each is strengthened through contextualized, continuous, recursive analyses applied to population segmentations:

1. Population-based, clinical modeling of care standards across conditions of management

2. Patient agency as a nexus of personalized education and psychology of self-care

3. Organizational performance as sustainable and systemic improvements in outcomes

The three foci preserve a balance in healthcare infrastructure—evidence of the interactions between providers, patients, and institutions—with an emphasis on continuous, applied knowledge, especially as it is interpreted by different people in different contexts. The framework for all analyses is the continuum of disease risk, a robust scope of detail than is absent in the prevention versus treatment dichotomy.

Infrastructure as Federal Performance Architecture

A health outcome infrastructure is going to facilitate the macro view of causality in a complex system, and each node in the “workflow” is a major decision domain. Throughout, the

Health Outcome Infrastructure Initiative – Paschane 2010© Page 2

infrastructure requires evidence of how the whole is affecting the disparate actions impacting behaviors downstream, and ultimately the outcomes in health and economics.

The following Federal Performance Architecture (FPA) is a proposed set of models and continuous analyses that enable a sustainable management of the causes of outcomes.

The Patient Protection and Affordable Care Act (P.L. 111-148) and Health Care and Education Reconciliation Act (P.L. 111-152) propose many changes to the National health system that can increase access, improve quality, and decrease costs. Throughout the Acts there are suggestions that the new system will be evidence-based, IT-centric, and effective at coordinating best practice services, from preventing ill health to managing chronic conditions. However, the Acts do not specify an FPA to organize and integrate the interdisciplinary research that enables desired outcomes.

The following list is 36 outcome goals in the Patient Protection and Affordable Care Act that have major knowledge dependencies and will require an effective FPA to support the coordination and routine use of evidence in guiding outcomes.

Section Summary Outcome Goal Major Knowledge Dependency Category

1102 Cover Employers’ Retirees Evidence-based standards for chronic and promotion care 1103 Consumer-Selected Plans Evidence-based designs for patient-tailored informatics 2406 Effective Long-Term Care Evidence-based standards for chronic and promotion care

Core Healthcare Cost Analyses

Core Healthcare Quality Analyses

Analyses:

Patient / Provider Use

of Self-Care Tools

and Training

Model:

Patient / Family Self-

Care Role in Care

Management

Model:

Population-Based

Standards of Clinical

Care

Analyses:

Provider Use of

Standards of Care

Analyses:

Mutual Satisfaction in

Active Treatment and

Self-Care

Analyses:

Clinical Decisions by

Pay Structure

Model:

Cost Offsets in Use of

Lower Priced Services

and Methods

Analyses:

Patient / Provider

Decisions on Visits

and Tests

Analyses:

Patient Use of Points

of Care by Price

Analyses:

Patient Use of

Methods by

Frequency and Costs

Model:

Cost Offsets in Timely

Detection and

Coordinated Care

Analyses:

Patient Use of Care

by Frequency and

Costs

Analyses:

Differences in Costs

Attributed to Initiatives

Decrease

Costs

Analyses:

Differences in Quality


Increase

Quality

Increase Health

Centers or Rural Doctor

Access

Model:

Energy & IT

Efficiencies

Analyses:

Facility Operations

and Construction

Model:

National View of

Cohort Needs and

Service Contexts

Analyses:

Engagements by

Service and Provider

Types by Places

Increase

AccessModel:

Complementary Care

and Care Seeking

Increase Health

Insurance Coverage

(Subsidy or Direct)

Model:

Growth of Intelligent

Infrastructure for

Service & AnalysisIncrease Health Care

Analytic Standards and

Evaluation

Increase Health IT in

Records, Navigation,

and ManagementAnalyses:

Value of Data from

Infrastructure Sources Analyses:

Maturity of

Performance

Architecture

Model:

Development of IT

Interface / Analytic

Layer

Analyses:

Control of Design and

Deployment of IT

Components

Model:

Organizational

Performance

Architecture

Analyses:

Mitigated Needs in

Service Contexts

Analyses:

Differences in Access



2701 Health-Neutral Premiums Independent analysis of demographic-based variability 2701 Useful Quality Monitoring Iterative behavioral and organizational outcome factors 2703 Home-Based Healthcare Evidence-based standards for chronic and promotion care 2706 Shared Pediatric Outcomes Independent analysis of demographic-based variability 2713 Cover Prevention Services Updated evidence in effectiveness of prevention services 2717 Improve Health Outcomes Evidence-based standards for chronic and promotion care 3001 Hospital Value Monitoring Iterative behavioral and organizational outcome factors 3004 Long-Term Care Monitoring Iterative behavioral and organizational outcome factors 3007 Provider Quality Monitoring Iterative behavioral and organizational outcome factors 3011 National Outcomes Strategy Evidence-based standards for chronic and promotion care 3013 National Quality Monitoring Iterative behavioral and organizational outcome factors 3014 Public-Viewed Monitoring Evidence-based designs for consumer-tailored informatics 3021 Innovative System Models Evidence-based standards for chronic and promotion care 3022 Shared Panel Outcomes Independent analysis of demographic-based variability 3126 Innovative Rural Models Evidence-based standards for chronic and promotion care 3201 Shared Plan Outcomes Independent analysis of demographic-based variability 3306 Educate Poorer Groups Evidence-based designs for consumer-tailored informatics 3501 Innovative Quality Models Evidence-based standards for chronic and promotion care 3503 Medication Management Evidence-based standards for chronic and promotion care 3506 Educate Shared Decisions Evidence-based designs for consumer-tailored informatics 3510 Patient System Navigation Evidence-based designs for consumer-tailored informatics 4001 National Prevention Strategy Updated evidence in effectiveness of prevention services 4002 Fund Prevention Strategies Updated evidence in effectiveness of prevention services 4003 Combine Prevention Models Updated evidence in effectiveness of prevention services 4004 National Prevention Message Evidence-based designs for consumer-tailored informatics 4103 Individual Prevention Plans Evidence-based designs for consumer-tailored informatics 4104 Finance Prevention Services Updated evidence in effectiveness of prevention services 4201 Finance Health Promotion Evidence-based standards for chronic and promotion care 4206 High-Risk Prevention Plans Evidence-based designs for patient-tailored informatics 4301 Trend Health Disparities Independent analysis of demographic-based variability 5601 Finance Health Centers Iterative behavioral and organizational outcome factors 5602 Designate Shortage Areas Independent analysis of demographic-based variability 5605 National Access Monitoring Iterative behavioral and organizational outcome factors

General Plan of Action

The Initiative will benefit from the growing interest and numerous collaborations that are in healthcare infrastructure nationally, and worldwide. The Initiative will fund a comprehensive collaboration of academic, industry, government, and consumer application of healthcare infrastructure research. The overarching method is to conduct short-term, recursive analyses where innovative changes in healthcare infrastructure can reveal practical and transferable knowledge to other places, under similar economic and institutional conditions.

Methodologically, the emphasis is on optimizing the availability of effective health care delivery in places where the populations’ general health or survival, and community development is undermined by chronically unresolved infrastructural weaknesses. Nevertheless, each resulting model will demonstrate parameters and principles that are useful to other settings, such as


remote and rural or diverse and congested communities. The evidence of effects is multi-dimensional, so likely to have broad, even global value as new infrastructural innovations are made apparent to the research and policy communities at large.

The Initiative relies on a base of interdisciplinary sciences because of the complexity of healthcare infrastructure. The figure below helps illustrate the reliance on a consortium of interests to help reveal best practices and needs for continual research to strengthen any healthcare infrastructure model.

Performance Architectural Science Systems

The President committed Federal departments to “use innovative tools, methods, and systems to cooperate among themselves, across all levels of Government, and with nonprofit organizations, businesses, and individuals in the private sector1.” Furthermore, OMB policy is to create and institutionalize a culture of open Government, one where the “integration of various disciplines facilitates organization-wide and lasting change in the way the Government works,” and the use of best practices “take advantage of the expertise and insight of people both inside

1 The White House, January 21, 2009, www.whitehouse.gov

Healthcare Infrastructure

Industry

Services

OperationsProducts

Government

Policy

Programs

Oversight

Academia

Education

Analyses

Monitoring

Consumers

Preparation

Segmentation

Communication


and outside the Federal Government, and form high-impact collaborations with researchers, the private sector, and civil society2.”

The integrated framework for the Administration’ objectives is the Performance Architectural Science Systems (PASS)3 that reinforce the maturity of (a) evidence-based management cultures; (b) agile integration of methodological best-practices; (c) IT-enabled awareness, training, and customer interactions; (d) incremental optimization of IT-enhanced business services; (e) robust capacity for shared knowledge of outcome causes; and, (f) natural openness to collaborative among communities of interest.

The long-term goal of a Federal Performance Architecture (FPA) is to fit applied scientific methods to all communication and management environments, so as to sustain recursive learning and collaboration of performance optimization across internal and external organizations.

To achieve a robust and useful FPA, IT offices across the Federal government will need to engineer, test, and validate recursive analytic methodological capacities (applied interdisciplinary science) that are user- and organization-specific information services; enabled and sustained through adaptive tools, IT-based training, and governance through communities of interest. The goal of the analytic capacities is to build sound, incremental, and long-term information sources for continuous improvements in operational effectiveness and efficiency, service quality and benefit, and various causes of team capacity and organizational outcomes.

The basis of each analytic capacity is a Model Performance Architecture (MPA); an estimated set of alternative performance causal pathways and workflow interactions based on classifying, analyzing, translating, and monitoring of data regarding formal and informal behavioral, organizational, and system processes. Each MPA is a baseline prototype of the analytic capacity within a specific domain of organizational operations. Through recursive analysis, verification, and validation, the MPA is engineered into a Segment Performance Architecture (SPA), fitted to the cultural, functional, and educational needs of teams, managers, and decision-makers.

The SPA is categorically delimited from other operations to control for complex organizational and human factors. Each SPA is a prospective candidate for a broader, integrated Organizational Performance Architecture (OPA) that affects the routine work culture, organizational strategy, and the general awareness of causes of outcomes. The OPA is engineered into a web-based environment to facilitate continuous, intuitive interactions with analyses. The web design facilitates awareness of outlier and pattern discoveries in performance, and validation of utility among users at various levels of organizational functions. An integrated OPA can provide key management functions, such as hierarchical representations of awareness for executive and stakeholder audiences, and in-depth statistical modeling for strategic planning across contexts, organizations, and people groups.

2 OMB M-10-06, December 8, 2009, www.omb.gov

3 PASS is a collaborative framework by SPARC technologist and UMBC methodologists.


Organizational Support

The Initiative would have to support and organize appropriate engineering (e.g., MPA, SPA, OPA, and FPA) through levels, functions, and domains of the Federal government.

The proposed team is four principal investigators and seven staff to organize and promote the research methodology to potential collaborators. The Emerging Healthcare Infrastructure Office will be responsible for organizing, vetting, and funding targeted, cooperative research projects consistent with the framework and scope of needs from the communities of interest.

Early Research Targets

The Acts include several useful components that can be strengthened in an FPA:

1. The CDC assessments on existing community-based chronic disease management programs can be improved by expanding to population-based evidence of previous health services, stratified to match the target populations—not only by age, but also by race, gender, conditions, and other factors.

2. The CDC analyses of best practices in the application of prevention programs to health care delivery systems can be integrated with research on contexts of service delivery and population health risk.

3. The AHRQ planning of training for primary care providers in evidence-based practices of prevention, promotion, and chronic disease care can be improved with continuous updates to population-stratified prevention effectiveness analyses, and clinical-population standards of care.

4. The CMS outreach and education assistance to low-income and aging populations provides evidence-based guidance in the design of patient-tailored informatics, and this will require online patient engagements that are sensitive to cultural, disease, age, educational, and technological aspects of prevention and chronic care management.

5. The CMS analysis of health plans’ care management outcomes will be enhanced with analyses of demographic-based variability in outcomes, attributable to the care standards administered by plans.

Major Sustainable Benefits

A robust Federal Performance Architecture (FPA) will help ensure that the disparate changes to the National health system are guided by evidence of their effects within the whole. This is a necessary capacity that can only be achieved through the cooperation of methodological and technological expertise. Not only the United States health consumers will benefit, but global


communities will benefit from the knowledge of health IT infrastructural research and modeling into best practices.

Specifically, the research community will coordinate useful findings from clinical and population-based data to provide (a) standards for chronic and promotion care, (b) updated prevention service effectiveness, and (c) consumer centered informatics to deliver both. These are the most likely concentrations for simultaneous improvements in quality, access, and decreases in overall cost through health IT research.

The research will enable tailoring of services, messages, and methods to patients in ways that meet their different needs and cultural interpretations of health. The research will also provide evidence-based support for decision making in major activities affecting institutional and societal goals. The on-going, public analyses encourage methodological visibility and data accountability, and ensure that the evidence-based decisions are sound.

Ultimately, the FPA will coordinate evidence-based (a) standards of care, (b) health informatics, (c) organizational effects, and (d) demographic fits, to meet the complex needs of health and health processes.

For more information, please call David Paschane at 202-256-5763.

Documents

Health Outcome Infrastructure 1.2