Monday, August 1, 2011

Julian Goldman, MD: Systems Thinking and More Efficient Healthcare

By Cody Ned Romano
Juli

To illustrate one of the healthcare industry's most vexing problems, Dr. Julian Goldman describes the hypothetical case of a nurse administering medication to his or her patient. After slipping a needle into the patient's arm, the nurse warns him that the medication may trigger a sharp decrease in blood pressure — then reassures the patient that if his vital signs change, a monitoring machine will produce a loud beep to alert hospital staff.

Dr. Goldman, an anesthesiologist and the medical director for biomedical engineering at Partners HealthCare, believes there might be a better way. "What if, instead, the vitals machine sent a signal to the fusion pump, automatically causing it to stop pumping medication before the sharp decrease in blood pressure?"

Dr. Goldman is developing this kind of life-saving technology: smarter, safer devices that can exchange information seamlessly across networks. In his October 25th keynote presentation on Day 2 of the MIT SDM Conference on Systems Thinking for Contemporary Challenges, Goldman will discuss some of the specific technological solutions that he and his team have created. In fact, Partners HealthCare is one of only three organizations in the United States that has created custom medical devices and registered them with the Food and Drug Administration.

Initially, Goldman's impetus to build safer medical devices was personal. During the mid-1980s, while training at the University of Colorado in Denver to become an anesthesiologist, he realized that doctors of his specialty faced many risks and pressures when performing procedures. "The field relied heavily on the vigilance of individuals," Goldman said. "That's a heavy load to put on one person: to never make mistakes and never miss anything."

A self-taught computer programmer, Goldman suspected that software could offset some of surgery's most serious risks. Alongside his training in anesthesiology, the doctor pursued a research fellowship in medical device informatics, exploring ways in which artificial intelligence could help monitor patients and assist doctors in making critical decisions. One application he developed, for example, made detailed observations about patients' kidney health using information about the pH levels of their blood.

Later in his career, once Goldman completed his training and began to work as a clinical anesthesiologist at the Massachusetts General Hospital in 2002, he recognized that developing better technology was only one facet of the problem — delivering improved medical devices to patients' bedsides also meant addressing a range of technical, managerial, medical, social, and political challenges. "Identifying a problem in healthcare, and thinking that one has a solution, is different than actually solving the problem," Dr. Goldman said. "I've begun to appreciate just how hard it is, and how long it can take, to alter the system, because it is so complex."

One political hurdle is the industry's lack of regulatory standards. Without adequate guidelines, many medical device companies design and manufacture products that are not interoperable — that is, they're incapable of interacting and exchanging useful information. Even if engineers succeed in extracting useful data from one machine, such as a patient's record or vital signs, they can't always ensure that another device will be able to interpret it. As a way of encouraging manufacturers to build standardized devices, Goldman chairs the ISO Technical Committee 121, an international standards organization, and belongs to several other groups dedicated to forming medical standards.

From a social standpoint, advancing interoperable technology will require doctors and engineers to collaborate in fundamentally new ways. "Engineers are like soldiers: if you give them the right tools, they'll confront serious problems very quickly," Goldman said. "Doctors, on the other hand, are interested in understanding all aspects of the problem, then brainstorming to discover new solutions." A member of both clans, Goldman proudly points out that the dichotomy is fading; he cites as evidence MIT's involvement in a consortium dedicating to improving healthcare: "The Institute has been extremely helpful to Partners HealthCare in advancing our projects and supporting our overall mission."

Despite complex technical and sociopolitical challenges, Dr. Goldman is confident that interoperable technology, which he dubs "plug-and-play," can rapidly alter the healthcare industry. He notes, for example, that USB Flash Drives, which can be used to swiftly transfer files between computers, faced similar interoperability problems less than 10 years ago.

"Medical devices are where the rubber meets the road, so to speak," Goldman explained, "where systems theories actually touch the patients. If we're going to build a more efficient healthcare system, there's an urgent need for us to consider all components of care from a systems-thinking perspective."

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