Healthcare is Different

Healthcare is Different

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I’m often asked why healthcare has been slow to automate its processes compared to other industries such as the airlines, shipping/logistics, or the financial services industry.

Many clinicians say that healthcare is different.

I’m going to be a bit controversial in this post and agree that healthcare has unique challenges that make it more difficult to automate than other industries.

Here’s an inventory of the issues

1.  Flow of funds – Hospitals and professionals are seldom paid by their customer.   Payment usually comes from an intermediary such as the government or insurance payer.  Thus, healthcare IT resources are focused on back office systems that facilitate communications between providers and payers rather than innovative retail workflows such as those found at the Apple Store.

2. Hiring and training the workforce – Important members of the workforce, the physicians delivering care, are seldom employed by the hospital.   This is rare if not non-existent in any other industry.  It’s as if Toyota built a factory that anyone can use but does not hire or train the workers who build cars.   If someone wanted to create a Toyota with wings and an outboard motor, they would have the freedom to do it.

3. Negotiating Price – Reimbursement no longer is based on a price schedule hospitals and professionals can control.   It is based on a prospective payment model such as DRGs that someone else designs and dictates.   Where else in the US do prices get dictated to a firm?

4. Establishing referral relationships – We cannot market services to those who control our patient flow due to Stark anti-kickback regulations.   In other industries, you can build relationships, offer special incentives, and arrange mutually beneficial deals to develop your referral business.   In health care, it’s illegal even when unilaterally funding an action would make things easier for both parties and the patient.

5. Standardizing the product – In most industries, the product or service can be standardized to improve efficiency and quality.   In health care, every person is chemically, structurally, and emotionally unique.   What works for one person may or may not work for another.   In this environment, it is difficult to standardize and personalize care in parallel.

6. Choosing the customer – In most other industries, you can chose with whom you do business.    Not so in health care.   If you have an emergency department, you must provide treatment even if the customer has no means to pay.

7. Compliance – Data flows in healthcare in increasingly regulated.    What other business, including the IRS, is required to produce, on-demand, a three year look back of everyone who accessed your information within their firm.

As I noted in my recent post about the Burden of Compliance “the more complex a health system becomes, the more difficult it becomes to find any system design that has a higher fitness.”

We are successfully automating healthcare workflows, motivated by HITECH incentives and the requirements of healthcare reform.   The 7 characteristics above have required vendors to create full featured software applications and organizations to create complex rollout/funding models that take time.  By 2015 we will be there and I will be proud of all we’ve accomplished, given that the constraints on the healthcare industry are truly different than industries which have been earlier adopters of technology.

John Halamka, MD, is the CIO at Beth Israel Deconess Medical Center and the author of the popular Life as a Healthcare CIO blog, where he writes about technology, the business of healthcare and the issues he faces as the leader of the IT department of a major hospital system. He is a frequent contributor to THCB.

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79 Comments on "Healthcare is Different"


Guest
Aug 11, 2011

Hi John. In my experience, virtually everyone considers their business/profession “different” and incomparable to others. And, indeed, most are different at the micro level. In a forest, each tree is different from every other, but a forest is a forest and what’s required to manage one isn’t dramatically different from managing others!

Likewise healthcare. If you focus at the micro level, all you’ll see are differences and you’ll have great difficulty bringing healthcare IT and administration into the computer age. On the other hand, if you look at healthcare in a broader context, simple solutions jump out at you.

None of the seven issues you cite as making healthcare different are unique in a macro sense. They are similar to those found in most other activities, and they shouldn’t be permitted to confuse and complicate solutions in healthcare.

1 Most businesses and professions are paid by some form of intermediary, whether it be a bank processing a check or a credit card company; and most have elaborate “back-office” departments to be sure they are paid in a reasonable time and correctly.

2 Hiring and training is difficult in every field. And many professionals and service people work in someone else’s facility, whether they be attorneys trying a case in a courthouse, a college professor giving a lecture, an electrician wiring someone’s building, or a tenor singing at The Met.

3 Most businesses and professionals don’t control the prices they charge. Competition often forces them to compete on price. Where price is agreed upon contractually, the purchaser usually forces adherence to the price even if it means you lose money. And most artists and performers rarely are able to dictate their fees.

4 Doctors referring patients to other doctors are no different than attorneys or accountants referring clients to other professionals. Yes, some industries pay referral fees but a great many, if not most, do not.

5 It is difficult for most service people to standardize their service. The facts and circumstances of most cases are different for attorneys. The wiring and plumbing in every building are different for electricians and plumbers. And contractors renovating a building usually don’t know what they will encounter when they open a wall.

6 Short of the ED, most healthcare professionals can choose their patients, just like other professionals do. And when other professionals do pro bono work, they must serve whoever comes along – just like doctors in EDs.

7 Virtually every enterprise has some form of compliance requirements. Many industries are carefully regulated; all are subject to IRS and State tax regulations.

In short, healthcare isn’t so different that I’m willing to make or accept excuses for its slow adoption of new administrative technologies. It’s bad enough that healthcare IT and administrative practices are so far behind, but continuing to make and tolerate excuses is unacceptable. How many people will die or be made sick unnecessarily between now and 2015 while we dawdle? And how many billions of dollars — that we can’t afford – will we waste? We should get on with it now!

Guest
Craig "Quack" Vickstrom, M.D.
Aug 11, 2011

And how many ppl will die b/c we adopt these new IT and admin practices? At this stage EMRs do more harm than good.

Guest
Dec 17, 2011

100,000 currently die in hospitals each year. Are you suggesting that the death rate is higher in those hospitals that have already implemented an EHR (soley as a result of that )? Great to have at least a few luddites around though.. I am guessing you also believe you are better then average and that it is someone else who isn’t providing the standard of care? Oh wait your retired? Ahh..

Guest
Aug 11, 2011

Health care administrative practices have been computerized a long time ago. This is not about tabulating numbers and indexing content. This is about computerizing and standardizing the thought process, the professional portion, in the practice of medicine.
This is about computerizing a non repeatable process which is not fully understood by anybody, including those who practice everyday.

Neither the tenor’s work nor the attorney’s work are anywhere near to being computerized. Nobody’s even trying.
Health care IT is blazing the trail. There is no comparable effort out there. And if we’re not careful, Dr. Vickstrom’s question will become very pertinent.

Guest
Aug 16, 2011

I agree with the above poster! We, the USA spends more money on healthcare then any other country. Yet we are number 36. If your state football team spent more money on training & promotions then anyother team wouldnt you expect them to be the best? We should expect more from our healthcare system and make it a HEALTH CARE System not a SICK CARE system. People need to be more responsible for theirself too. Dont just go to the doctor and say fix me becuase guess what they go out and Google your symptoms just like you can do at home.

Guest
James S. Walker
Aug 11, 2011

Merle is correct. There is no good reason for delaying an outright deliberate effort to develop some form of advanced standardization of the delivery system. The status quo is unhealthy for none of the affected parties, and the airline industry’s platinum safety record is proof that an optimized system is plausible; we are morally obligated to move this forward right now.

Guest
Aug 12, 2011

“Air France says the plane overwhelmed properly trained pilots with a blizzard of confusing signals and misled them because of a “trap” caused by erratic warnings.”

AF 447 crashed into the Atlantic, killing everyone aboard.

Guest
fid
Aug 16, 2011

And yet if you look at the airline industry as a whole, it has a much better safety record than the health care industry.

Guest
Aug 12, 2011

Craig, as a practicing physician you know better than I if EMRs “do more harm than good” but it is clear that most doctors don’t like or want the EMR systems that are out there. They simply don’t work for them – and subsidizing their adoption doesn’t make them more acceptable. We should be encouraging the development of more functional and useful EMR systems rather than forcing the adoption of what’s available today. Similarly, patients don’t want their records accessible via Internet-linked servers yet we continue to promote and fund the development of such networks. Why? So we can have an unwieldy, very expensive system by 2015 that nether providers nor patients want?

Margalit, I think we’ve had this conversation before. Ultimately, this may be “about computerizing and standardizing the thought process, the professional portion, in the practice of medicine.” But that’s many, many years away. Today, doctors can’t even do the basics. They can’t exchange patient medical records or access a patient’s records that were created by the patient’s other providers! They can’t coordinate care. They don’t have access to results of tests ordered by other providers, etc. IMO, this IS about content and the mechanics of getting a patient’s complete medical record in the hands of the doctor who is treating them — so shouldn’t we start there? That’s all John is referring to when he says that “By 2015 we will be there. . . . “ I agree with James Walker: “we are morally obligated to move this forward right now” and we can!

Guest
Aug 12, 2011

“So we can have an unwieldy, very expensive system by 2015 that nether providers nor patients want?”

I think all the evidence indicates that that is the goal.

Guest
Aug 12, 2011

Care to cite for us any empirical evidence that such is the case? WHOSE “goal”?

Guest
Aug 12, 2011

Valid point. I was using the word “evidence” in an informal sense.

But I think that if one looks critically at current EHRs, including what they can do, what they are required by law to do, and what they can’t do, that it is very reasonable to conclude that we are creating an enormous and expensive system that serves government and insurer needs at the expense of physicians and patients.

Guest
Aug 12, 2011

Apropos of your point:

http://www.modernhealthcare.com/assets/pdf/CH75065812.PDF

Though, I would still take issue with “goal.” Perhaps “unintended consequences,” which bedevil many, many initiatives.

Guest
Aug 12, 2011

Holy moley, I can’t believe I agree with anything Renee Ellmers said.

She won her House seat in North Carolina by campaigning against the not-at-ground zero not-a-mosque.

Guest
Dec 17, 2011

Wrong 100% of all docs at the VA (vs DOD) use and have used an EMR for the past 20 years.. The result? The hightest quality care in the country. Vets clamoring to get their care there and 1/4 of all residents in the US trained on their systems.

Guest
Dec 18, 2011

There’s no question that the VA’s system works beautifully– up to a point. That “point” is that it does not contain the warrior’s pre-enlistment medical records, neither does it contain any records of care received outside the VA system. Similarly, for active military personnel and their dependents, none of the systems used by the different branches can exchange information, neither can they share or receive records with civilian care providers. And moving outside the military it is worse. Virtually none of our legacy EMR vendor’s systems can share simple patient records such as progress notes, and most cannot even generate an electronic copy of their electronic progress notes — they have to print them out! Last point, none can integrate copies of a patient’s paper records into their system — a rather serious shortcoming since 75% to 80% of our physicians keep paper charts.

Guest
Aug 12, 2011

Merle, I don’t see why we need to create yet another huge emergency.

Doctors can and do coordinate care. They can and do exchange medical records. They don’t use computers to do that. They use other means, such as fax, telephone, and yes, paper records. Could we make these exchanges faster with computers? Yes. Can we make these exchanges better with computers? Perhaps, but I am not certain.

If you think that standardizing the thought process is a futuristic thing, think again. All EHRs must (by government ruling) contain clinical decision support, reminders, alerts, encouragement to use this or that medication (per PBM wishes), and this type of assistance is increasing to standard definition of care plans, team members, recording/reporting therapeutic practices that are “wasteful”, required questioning of patients and required counseling, to just name a few.

There is more to this debacle than doctors being technology averse, or technology being immature.

Guest
MD as HELL
Aug 12, 2011

Once you standardize the care you get a standard outcome. Will that be good enough?

Guest
Aug 12, 2011

Axiomatic to QI is variability reduction — “standardize.” Reducing variability improves “expected values” — “outcomes.”

Don’t take my Great Unwashed word for it. Contact my old QI mentor, Brent James, MD, MStat (IHC)

Guest
Craig "Quack" Vickstrom, M.D.
Aug 12, 2011

Good luck with “reducing variability” in what walks thru the door, BobbyG. Good luck “standardizing” what patients will and won’t cooperate with.

It really is interesting, how clueless you academic dilettantes really are. You really think the practice of medicine can be reduced to a care plan. This would be funny if it weren’t so pathetic. I am, however, thankful you don’t take care of patients.

Guest
Aug 12, 2011

Right. “Academic dilettante.” Nice. I am not in academia. I work with providers. You have no clue as to who I am. Ask Brent James if I’m a “dilettante.”

You clowns and your “perfectionism fallacies” crack me up. What JD Klienke calls reflexive “policy tear-down artists.”

So, because it’s gonna be difficult, we simply shouldn’t even try. And “No One But MDs Need Apply.” Right. Spare me your condescension.

‘Good luck with “reducing variability” in what walks thru the door’

See “The Hot Spotters.”

Guest
Craig "Quack" Vickstrom, M.D.
Aug 12, 2011

O no! You are trying right now. I have work with foul fruits of your standardization labor every day in the clinic now. Lots more time spend documenting things on the computer (when it works). Lots less time spent fixing problems. I don’t partake in the “perfectionism fallacy,” as IT and admin practices that are competent would be acceptable to me. I have never asked for nor expected perfection.

As long as you expect the practice of medicine to be confined to a standardized care plan on a computer, you deserve nothing but my condescension.

Guest
MD as HELL
Aug 13, 2011

The patient brings the variables. As I have said before, give doctors smarter patients and they will give you better outcomes

Guest
Aug 13, 2011

So, add a Weschler score entry in the Demographics template (or, would it go under Vitals)? Or, have a Weschler inventory template within the NEURO section of ROS?

Impractical? Perhaps data entry cells for education level and GPAs might serve as correlative proxies, ‘eh?

/s

Guest
MD as HELL
Aug 14, 2011

Outcome stats should include all the variables

Guest
Aug 12, 2011

“As long as you expect the practice of medicine to be confined to a standardized care plan on a computer, you deserve nothing but my condescension.”
___

Go right ahead. Simplistically misrepresent my views. Enjoy yourself.

I am an open book. You are not. Telling, that.

“you expect the practice of medicine to be confined to a standardized care plan on a computer”

No, “You get what you INspect, not what you EXpect.” – James W. Dillard, PhD, my original professional mentor in the 1980’s.

http://www.bgladd.com/papers/ITORL1.PDF

Guest
Craig "Quack" Vickstrom, M.D.
Aug 12, 2011

My apologies to all, especially BobbyG, if I have been a bit uncivil. But in my rather short medical career, I’ve heard so many promises of streamlined processes, EMRs and QA programmes that would supposedly make my patients better and my job easier. They have not been kept. Not a one. So, I’m a bit suspicious and a bit nasty when confronted with more of them. I do beg your pardon.

Guest
Aug 12, 2011

No harm, no foul. We all need to pull together. And, yes, dissent is part of the scientific method.

As should be obvious from my REC blog work to date, I am no reflexive apologist for HIT.

Guest
Aug 12, 2011

“See “The Hot Spotters.””

Let’s do that Bobby. Where in our mighty IT solution do we find the part about sitting in a hospital room with a “hopeless” patient for hours trying to understand what makes him tick (or not tick)? Or visiting him at home and noticing things? Or organizing and participating in tenants meetings? And that was the doctor doing these things, not a high school educated serial case manager.

Sure, we can standardize treatment for sinus infection, headache and strep throat. But are we having huge problems in treating these things now? Are people dying from lack of standards in treating trivial concerns? Are we spending fortunes on these problems? If not, what is the ROI in tinkering with these things?
And what is the ROI in spending billions of dollars to make sure that the use case of someone showing up naked, unconscious and alone in the ER is satisfied, and all the data about that person is available at the click of a button (or two, or three)?

I may be misreading the “Hot Spotters”, but my takeaway was that in order to fix the big problems we need anything but a standard approach to each and single one. Yes, IT can help with identifying the people, tracking and measuring improvements (savings), but it was high-touch non-standard human intervention and just plain caring that made a difference.

Perhaps that’s what we need to standardize – that each patient will be treated as a unique individual, with unique problems and unique circumstances and be provided with as much time and effort as necessary to allow for a unique solution. Some refer to this as patient-centered care, and strangely enough it is cheaper than the cattle herding model we now use, and it is rather different than data-centered care.

Sorry for the rant. It’s not aimed at you Bobby…. :-)

Guest
Aug 12, 2011

“I may be misreading the “Hot Spotters”, but my takeaway was that in order to fix the big problems we need anything but a standard approach to each and single one. Yes, IT can help with identifying the people, tracking and measuring improvements (savings), but it was high-touch non-standard human intervention and just plain caring that made a difference.”
___

That suffices for me, Margalit (you, for whom I have the greatest respect). I wrestle with these issues every day. Every day. I could not be more sensitive to the problematic ongoing loose coupling of cause and effect in medicine.

Recall when I wrote the year before my daughter died (1997’ish):

“…First, the many physicians I have come to know in the past few years are in the main acutely sensitive to the problems of clinical conceit and “paradigm blinders.” Indeed, the Utah pediatrician’s”$100 bill” wisecrack was offered to an audience of doctors and their allied health personnel during quality improvement training. Second, the body of peer-reviewed medical literature does not constitute a clinical cookbook; even “proven” therapies– particularly those employed against cancers– are generally incremental in effect and sometimes maddeningly transitory in nature. The sheer numbers of often fleeting causal variables to be accounted for in bioscience make the applied Newtonian physics that safely lifts and lands the 747 and the space shuttle seem child’s play by comparison. Astute clinical intuition is a necessary component of a medical art that must, after all, act and act quickly– so often in the face of indeterminate, inapplicable, or contradictory research findings…”

http://www.bgladd.com/1in3/

I’m no newcomer to this party. And, again, no reflexive apologist.

Guest
Aug 12, 2011

“it was high-touch non-standard human intervention and just plain caring that made a difference.”
___

I should add that when I was undergoing the IHC Brent James CQI training in 1994 he made the pointed observation during the Plenary that medicine was both “high-tech and high-touch,” with the latter being more important overall in terms of resolution/patient acceptance irrespective of clinical outcomes.

Guest
Aug 12, 2011

You know, on a more materialistic level, I sometimes wonder if the increasingly disappearing high-touch from medical care is not largely responsible for both the malpractice suits epidemic and the futile care demand increase, which goes to the patient acceptance you are mentioning… It’s hard to accept anything from a drive-by stranger, even if he/she has a computer on hand.

Guest
Aug 12, 2011

The long answer, IMO, is “yes.”

Guest
Aug 13, 2011

See my reference above to Air France Fligth 447. The systems didn’t allow the pilots to do what they had been trained to do.

Guest
Aug 12, 2011

I had my daughter referred to as “the Hepatoma in 7B.” I personally observed Rounds at UCLA neurosurgery after her brain met hemo blowup, wherein Attendings, residents, and med students discussed “the case” in the 3rd person IN her presence around her bed, like she wasn’t even there.

Imagine.

Guest
steve
Aug 13, 2011

You guys should not necessarily extrapolate from university care. In private practice, the personal touch is still valued quite a bit. The problem for private guys is high touch while keeping costs down. You cannot spend an hour with every patient answering every question (studies show patients forget anyway) and have lower costs.

You also touch upon a basic conundrum in medical care. Most docs are geeks. If you want touchy feely, you can have docs who dont understand the tech they use. It is hard to have it both ways. WHat should I do with my docs who rated in the 99th percentile for national quality of care measures, but ranked in the bottom 25th percentile on their Press-Gainey scores? Should I hire less competent, but nicer people?

Steve

Guest
Aug 13, 2011

Totally agree about the time billability constraints of private practice. You also make a good point about the difference between tech/analytic chops and personality.

“Should I hire less competent, but nicer people?”

You need BOTH “competencies” overall wherever you can get them.

And, “pcp,” it’s a blinding glimpse of the obvious that sometimes complex systems will fail, occasionally with catastrophic upshot. Not sure I get your point.

Guest
pcp
Aug 14, 2011

My point is that the crucial component of the system is the properly trained individual, be she pilot or physician.

If the system is not designed to support her functioning at the highest possible level of excellence (which critically includes the freedom to go against all protocols when appropriate), we get disasters.

There is much in the direction in which health care is headed that works for insurers and government agencies, but is directly hostile to excellence in physician performance.

Guest
Aug 14, 2011

Again, I agree with your final point (and I would add the HIT vendors to the list). Just not that the Air France tragedy is an appropriate analogy.

Guest
Barry Carol
Aug 13, 2011

Steve –

From a patient’s perspective, if I had a rare condition or something that was difficult to treat, I would be willing to tolerate a certain amount of arrogance or less than stellar bedside manner in order to access the doc’s clinical expertise. For most circumstances, though, I think a doc who ranks as the financial equivalent of investment grade or at least B+ in academic terms clinically with respectable (at least middle of the pack) Press-Gainey scores would be preferable to the doc who ranks at the top clinically but poorly on Press-Gainey. That’s just my opinion, of course. Others may feel very differently

Guest
Aug 13, 2011

Steve,

High-touch does not necessarily translate to touchy-feely. For example, as Barry noted, for a highly skilled acute intervention, you should be there before, during and after. You may come across as arrogant, down to earth or whatever, but you should be there and that one patient should be your sole concern during the time that you are there. I would suspect that your stellar docs fall into this category, no matter what the patients’ perceptions are, because I don’t think you can do a good job otherwise (in any profession).

Even for PCPs, I’m not sure that touchy-feely is the real requirement. It may be for some people in some cases. I think high-touch encompasses thoroughness and a genuine commitment to the individual patient’s best interest. And yes, time is a big problem created by our penny wise and pound foolish payers (public and private alike).

Guest
steve
Aug 14, 2011

First, we are an acute care trauma center and a tertiary care facility. Much of what we do is high risk. How much competence do you want me to sacrifice? How do I quantify that? When the 17 y/o trauma patient or the 80 y/o AVR dies, do I tell the family it is ok, because the doc I hired was nice to them before the patient died?

” I think high-touch encompasses thoroughness and a genuine commitment to the individual patient’s best interest.”

Hence, our 99th percentile on performance measures. To do well on Press Gainey scores, you need to go beyond competency to real touchy feely.

Now, here is the other side of the equation. From the business side, I have every motivation to hire touchy feely. As long as our outcomes are above average, as long as we do not care about trying to provide the best possible care, we can make a lot more money. Touchy feely gets you the cushy, high paying surgicenter jobs. It makes patients come back. Administrators love it. While it would be nice to have docs who are good at both, people just are not hard wired that way.

Steve

Guest
Barry Carol
Aug 14, 2011

Steve –

Again from a patient’s perspective, I think there is a big difference between surgeons and other doctors. If I need surgery such as a CABG or a hip replacement, I want to know that the surgeon has done a lot of the procedure that I need, has been practicing for quite some time, is board certified and generally well regarded in his field. I don’t care nearly as much about his personality, especially since my interaction with him will probably be limited to the surgery itself during which time I’ll be under anesthesia anyway and a follow-up visit or two to ensure that things are healing and progressing as they are supposed to. For PCP’s and non-surgical specialists with whom I am likely to have an ongoing and long term relationship, personality and the personal chemistry between the two of us is much more important though I still care a lot about competence as well. I recognize that some specialists like urologists, gastroenterologists, etc. also do surgery but most of the patient’s encounters with them over time will be for non-surgical checkups and monitoring.

Do you make a distinction in your hiring process between surgeons and non-surgeons? Also, how do you evaluate competence before you hire them? Presumably, they also need to be a good cultural fit with your group and your hospital.

Guest
steve
Aug 14, 2011

Barry- I am an anesthesiologist. We have about 45 providers now. I am corporate president. I look for clinical excellence first. I have recently hired some CT fellows, bringing in candidates from Cleveland Clinic, Penn, Duke and Texas Heart. I rely upon evals from program directors and only hire people when we can get recommendations from people we know.

personality issues have become more important as we need outgoing, friendly types if we want the better paying work at surgicenters. Hospitals have also been pushing Press Gainey scores. We spend a lot of time interviewing, since we start way ahead. I tell people they will work a little harder and make a bit less than the national average. I also tell them the hospital is supportive of our efforts to practice quality medicine. So far, it has enabled me to recruit clinically solid folks. We dont rank in the 99th percentile every year, but we are always in the upper percentiles. Yet, we are in the middle or low middle Press Gaineys. Should I change? Why?

Steve

Guest
Barry Carol
Aug 15, 2011

“Should I change? Why? “

Steve –

Absolutely not! It sounds like you and your people are doing a great job and providing great care. Middle of the pack on Press Gainey should be adequate for surgeons and anesthesiologists. For the latter, most patients don’t know them and have no role in choosing them anyway. I’ve had four surgeries, including a CABG that required an anesthesiologist. I had no role in choosing any of them and it didn’t bother me. I found the surgeons through referring doctors that I trusted.

Surgeries lend themselves better than most care to outcomes measurement, including complication and readmission rates, though the risk adjustment process is less than perfect, I’m sure. I would think your group’s reputation for clinical excellence should generate positive word of mouth among both patients and referring docs throughout your region.