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The Informed Brain in a Digital World
Interdisciplinary Research Team Challenges

Interdisciplinary Research Team Challenge 6:
Determine how the effects of the digital age will improve health and wellness.

Challenge Summary

As noted in IDR Challenge 1, healthcare systems offer a major test ground for the implementation of methods for efficient lifelong learning that could benefit society through improved health and wellness.  The challenge is the cost of doing so effectively and the willingness of care providers and care consumers to adapt their practice and lifestyles to innovative but demanding new technologies. Two potential areas of opportunity are 1) improved career-long education of care providers that would expand the primary care giver roles beyond physicians; and 2) improvements in physician-patient communication for enhancing prospective heath strategies.  The team challenge is to examine current strategic efforts aimed at these or other comparable health and wellness endpoints and devise practicable means to exploit the digital information explosion in these proposed solutions.

Improved Career-Long Education
In current medical education, the medical student must learn not only the relevant facts and their application to disease mechanisms, treatment, diagnosis and prevention, but assimilate into that body of working knowledge all the new facts that will emerge during their careers as practicing physicians. Most such practice emphasis is devoted to solving acute problems in ill health, injuries, infections, acute cardiovascular or cerebral pathology, or persistent functional problems such as diabetes mellitus, obesity, and epilepsy.  This crisis-directed practice may also confront tomorrow's clinicians, but given the growth in biomedical understanding of disease mechanisms and the social, genetic and environmental factors that can tip the odds from vulnerability to resistance to these disease conditions, how can digital information help? Snyderman and Williams have suggested a strategy that would expand the care team from physicians only to include paraprofessionals (physician assistants, geneticists, epidemiologists, and information specialists) who will be needed to assimilate into practice ever more rapid medical discoveries. How will the digital information explosion be refined into the knowledge needed to enhance the likelihood of success for this strategy? Given the reductions in hours allowed by the Accreditation Council for Graduate Medical Education, the training career opportunities for post-graduate medical education has become seriously constrained by limits in maximum hour work weeks, reducing the time to develop experiential competencies in the skills needed for effective practice, a problem that will be even more critical if the ultimate national healthcare plan reduces the Medicare contributions that presently fund for post-graduate clinical training.

The rapidly broadening armamentarium of powerful new medications requiring lifelong dosing and their complex interactions with individual patients creates multiple potential adverse drug interactions, specific to individual patient diagnoses. While the IBM-Watson project and other expensive, proprietary differential diagnostic systems, are beginning to enter some forms of managed health care, can such computer-assisted diagnostic judgments become an acceptable form of medical practice? Therefore, the underlying problem remains of devising a medical educational system that will not only motivate students to become skilled in basic academics and in the technology of medicine, and remain able to assimilate new knowledge, new medications and new forms of medical practice. 

Improved physician-patient communication
If a goal of modern medicine is to improve the general state of societal health, the strategy suggested by Snyderman and Williams calls for enhancing prospective heath strategies, by which any individual would maximize their opportunities for lifelong wellness by a team of health practitioners who can implement strategies for disease avoidance based on new knowledge in the genetic, environmental and social factors that can determine disease onset, progression or resistance.  Levinson and Pizzo have called attention to some of the ways in which current and future patient-physician communication could be improved.  Much of such enhancing communication has traditionally been face-to-face in office or bedside, but the onrush of digital information technological options could fragment this budding communication option.  If the financial inducements (from the pool of Medicare finances) being offered to hospitals, group practices and individual practitioners require the demonstration of meaningful use of electronic health records, how can digital technologies avoid becoming a barrier between the doctor who is entering patient details of complaints, findings and treatment history – while still finding the time to listen to the patient’s concerns? How effectively can the Office of the National Coordinator for Health Information enforce that such electronic health records will be interoperable across medical practice systems while ensuring confidentiality of individual personal details and vulnerabilities, and at the same time serve as a national epidemiological surveillance for the emergence of communicable diseases or adverse drug effects?

Improved Health Management by Physicians and Patients
Another major shift in the practice of medicine is the development of digital communication systems to administer medical treatment at a distance, educate patients, and monitor disease states, often termed “telemedicine”.  An extreme example is the tele-intensive care unit (tele-ICU; Goran 2012).  The critical “life-or-death” importance for correct testing, diagnosis, treatment, and moment-to-moment monitoring and constantly reacting to changing health issues places tremendous demands on the multi-modal digital communication system and the human team.  How can information, knowledge and expertise from a high-end hospital improve outcomes for linked ICUs lacking such expertise?  In less tense applications, medical management of a disease from a distance is becoming more and more frequent and health-consumer directed. This is due to the availability of accurate patient-worn sensors for blood pressure, heart rhythms, and blood metabolites – not only in daily monitoring but in educating subjects to monitor their blood sugar levels, calculate carbohydrate content of foods they eat, and understand the effects of exercise on insulin utilization, and prevent (or reverse, if needed) hypoglycemic episodes, etc.  As in the tele-ICU, it is the integrations of the technical digital components with the human-interaction components that pose the real challenge for the effectiveness and efficiency of system development, especially optimizing the human aspects.  How can all the various aspects be integrated to a seamless operation?  How can we quickly identify areas of friction (machine/human) and quickly fix them? What would be the properties of an ideal tele-medical application?

Key Questions
How will increasing technology shape health and medical decision making?

How will the digital information explosion be refined into medical training?

Will computer-assisted diagnostic judgments become an acceptable form of medical practice?

How does medical education motivate students to use digital information to be life-learners of innovations in medicine?

How can digital technologies avoid becoming a barrier between the doctor and patient?

How can electronic health records be used to maximize patient outcomes?

Can information, knowledge and expertise provided through digital communication systems improve outcomes for those in the field or for those who lack such expertise?

What would be the properties of an ideal tele-medical application?
 

Suggested Reading
Brailar DJ. Guiding the health information technology agenda. Health Affairs 2010;29:586-595. (Accessed online March 28, 2012: http://content.healthaffairs.org/content/29/4/586.extract.)

Goran SF. Making the move: From bedside to camera-side. Critical Care Nurse 2012;32:20-29. (Accessed online March 28, 2012: http://ccn.aacnjournals.org/content/32/1/e20.abstract.)

Halamka JD. Making the most of federal health information technology regulations. Health Affairs 2010;29:596-600. (Abstract accessed online March 28, 2012: http://content.healthaffairs.org/content/29/4/596.abstract.) 

Levinson W and Pizzo PA. Patient-physician communication.  It’s about time. JAMA 2011;305:1802-1803. (Accessed online March 28, 2012: http://jama.ama-assn.org/content/305/17/1802.full.) 

Moffett TE, Arseneault L, Belsky D, Dickson N, Hancox RJ, Harrington H, Houts R, Poulton R, Roberts BW, Ross S, Sears MR, Thomson WM, Caspi A. (2011) A gradient of childhood self-control predicts health, wealth, and public safety. Proc Natl Acad Sci U S A 15 February 2011;108(7):2693-8. (Accessed online March 28, 2012: http://www.pnas.org/content/early/2011/01/20/1010076108.) 

National Council for Patient Information and Education web site. (Accessed March 28, 2012: http://www.talkaboutrx.org/index.jsp.)

Snyderman R and Williams  RS. Prospective medicine: The next health care transformation. Acad Med 2003;78:1079-1084. (Accessed online March 28, 2012: http://journals.lww.com/academicmedicine/pages/articleviewer.aspx?year=2003&issue=11000&article=00002&type=fulltext.)