If I Were as Sexy as Atul Gawande


While I don’t much feel sorry for myself these days (I used to, but that was years ago now), I had a recent pang of it reading Atul Gawande’s new book The Checklist Manifesto.

In this bestseller, he points out that much of what ails us in health care is the lack of good checklists.  Not just the lists of course, but the fact that much of health care is now rote stuff that we already know how to do. What we need to do is accept that and stop treating the work like it’s a craft-brewed, once-in-a-lifetime invention. We need to start treating it like a complex set of tasks that needs to be done well, in order, every time and preferably by technicians specially trained to repeat the list.  This Gawande guy is so smart, good-looking and bloody silver-tongued, that he gets to saunter out with what athenahealth has been trying to say and do for the last decade—only he gets published right off! I just know he’s gonna get one of those ooey gooey softball interviews with Terry Gross and even get to meet Obama over it.   I feel like the guy on the FedEx commercial who didn’t get credit for the idea because he didn’t “go like this —” when he offered it.

OK, enough whining. Spilt milk aside, Gawande is right.  What he suggests is what all the innovators in health care that I like are doing.  In general, we start with the very lamest junk first and then work our way into the complex.  In athenahealth’s case, we started with the billing process, of all things.  Most practices and hospitals treat it like it’s one of the dark arts when it’s actually just a complicated process problem that needs to be broken into checklists, hopefully in 6th grade English, and then served up in the moment of truth to those doing the work. It could be a scheduler, a nurse, a doctor, every single conversation in healthcare can contribute to a clean claim—or break it. The Internet has been a terrific aid for us in this task.

athenaNet®, since it is web-native, is available everywhere and usable by everyone.  You don’t need much training or specialized skill to use web-apps these days. We are still missing a lot but we now have the checklists necessary to make it so mostly every claim in every specialty glides right through. It has taken us a decade of updating our checklists and we have found over 40 million (no kidding!) reasons why medical claims can go wrong AND we still have miles to go. But we are well on our way.

With billing under some semblance of control, we were able to move about five years ago to medical records documentation and management.  Here the work was initially only about filing. It was not about complex protocols for treatment of chronic disease, it was just about not losing faxes.  Did you know that almost everything that the average doc gets today about patients comes via fax …EVEN IF HE OR SHE HAS AN EMR??! The average provider on our network gets over 1,100 faxes a month!! I got three during all of 2009!

We have put tens of thousands of hours of software and analytics into getting those faxes read and filed correctly—and of course into finding the senders and introducing them to this neat thing called the Internet.

Next, we found that there was money for doctors in executing on certain chronic care checklists. They are called Pay-for-Performance (P4P –cute moniker eh?) programs.  So now we are building checklists in that same 6th grade English into every conversation about scheduling, every intake with a medical assistant, every exam and of course every physician order. Ahh, those humble beginnings in the claim worlds are starting to show up in the exam room!  We aren’t docs. Never will be. Don’t want to be.  We just want to clean up after them and keep track of all the checklists that they need to stay safe and productive.

Now we are onto patient communications.  Same gig here. When are people ready to deal with their appointments? Their lab results? How do they want to deal with the financial aspects of health care?

athenaNet is learning the answers to those questions. We are learning literally millions of lessons in this pursuit.  Little eeny-teeny lessons, yes, but they add up.  Because all our clients do their billing and medical records and patient communications on ONE instance of one web-native application, we can push each teeny learning out to all our clients as they need to know it in real time.

Drop by drop, we are draining the medical confusion swamp revealing only the hard, and important, stuff. That’s the stuff for which we don’t know the checklist, the stuff that makes up (or should make up) the REAL practice of medicine in 2010.

So congratulations Atul, you sexy SOB.  You are onto the answer to what docs need in this book… but pack a lunch! There is a long, hard slog left in getting those checklists together and useful to the point where they take the drudgery and absurdity out of doctors’ work and let them focus on the important stuff.

PS—In order to get people DOING those checklists there has to be a market for the work in them. More on that next time.

Jonathan Bush co-founded athenahealth, a leading provider of internet-based business services to physicians since 1997. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School.

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18 replies »

  1. In response to MD as Hell.
    Yes, turning every process into a checklist can be a horrible idea. The idea of the checklists used by pilots and nuclear plant operators is different. Those checklists are brief, comprehensive, and tested to verify efficiency. They’re just a means to an end, not an end in itself. Take a look at the IHI’s version of the WHO surgical safety checklists (http://ow.ly/2faUy). They add 90 seconds to a surgical procedure and ensure that key pre- and post-operative steps are taken to provide a safe, efficient outcome. They don’t attempt to take over the entire operation, and they don’t dumb anything down.

  2. Being sexy is not easy, it requires discipline and food diet. Proper exercise also is one way to have a sexy body. But today with the advancement of technology like the Internet , you can have a desired body in just a matter of days. But all you have to do is pay much amount to have a sexy body like Atul Gawande.

  3. John,
    Kareo was designed for and is used by practices with 1-4 providers, and by medical billing services serving up to 100 providers, many of which are solo practitioners. Since practices of this size represent over 420,000 of the 900,000 physicians in the US, I suspect they would have a good argument that they are, indeed, “prime time.” We certainly think so.
    If you were looking for a billing solution to serve a large practice or hospital, then we would tell you that Kareo is not designed for that purpose. But we have several thousand users who would argue that Kareo is a well-designed, easy to use, affordable option for nearly half the physicians in the US, along with other healthcare providers. If you look on our website at http://www.Kareo.com, you will find testimonials from more than 100 users who highly recommend Kareo, with more added on a regular basis.
    In addition, Kareo regularly issues updates to our software with new features requested by our customers; it’s very important to us to be responsive to our users’ needs and respond quickly to meet their needs. If it’s been some time since you tried Kareo, you may find that it has changed substantially since then, with many additions and improvements.
    We appreciate your support of Web 2.0 players, and hope that you will keep an open mind for those of us who are striving to provide economical, useful software options for practicing physicians and, indeed, continually improving our solutions.
    Kathy McCoy
    VP, Marketing

  4. Great conversation, I would like to hear more about pros and cons of checklist. AHRQ has quite a few checklist on safety available and I was wondering if anyone uses these in daily practice.
    Jeff Brandt

  5. Robert,
    I am not suggesting you can’t manage new users, by scale I meant the comprehensive, multidimensional needs of a practice. I have used Kareo and by their own admission, they are not built for prime time but smaller, simpler practice situations. I have not used your solution, but the fact you recommend Kareo in tandem with your EHR concerns me. You’re only going to be as good as your weakest link. Conversely, the wisdom of using a stand-alone EHR that is not fully integrated with the PM and billing escapes me, when there are many such SaaS solutions available and the argument for integration is very, very strong. If your standalone business model is enough to be compelling then so be it.
    I understand that you intend to meet the HHS meaningful use guidelines but would take some comfort in those 50+ providers, some of whom are fully integrated SaaS providers that have already demonstrated the ability to meet earlier CCHIT certification standards and are committed to meeting the meaningful use guidelines before I would bet on solutions that have never demonstrated they can run their first certification gamut. That said, its great to have ambitious Web 2.0 players in the space as there aren’t enough of you and I expect you’ll continue to improve your solutions.
    John Gordon

  6. John Gordon – I would challenge your statement that “more recent start-ups like Practice Fusion and Kareo while intriguing don’t scale and their capabilities are quite limiting.” Practice Fusion continues to add about 170 new users a day, and the percentage of new users who become very-active users is increasing daily as well. The focus of the company is to encourage usage (it is a use-based business model, rather than a sales-based one), and is in alignment with Meaningful Use. New features are rolled out to all users (it is a web-based, pure-cloud application, after all) every 2-3 weeks. The product development strategy is to become fully HHS Certified by the time that such Certification comes into place. Absolutely everything needed for full Meaningful Use is currently rapidly being developed. I’d encourage you to stay tuned as things develop this year.
    Robert Rowley, MD
    Chief Medical Officer
    Practice Fusion EMR

  7. RealMed had the solution many years ago, but the insurance industry killed that product. There is no solution to a moving target. Just like our treatment of bacteria, you come up with a new product and the industry will find a way to become resistant. Sorry for the wish for standardization, but it is less expensive to solve a fixed problem than a dynamic one. This is especially true when you are talking about an area that does not improve personal health. “Claims”

  8. I respect Athena’s salesman in chief and what his company is accomplishing. However, his ability to wedge a self serving ad into a “book commentary” is the biggest differentiator between him and his competition. We can all agree that the industry is a muddle of increasing complexity, challenge and change for physicians. There are so many much more sophisticated analogues in industry after industry (i.e., salesforce) that anyone who claims any credit for bringing a modicum of order (e.g., lists?) to the backwater processes here should be ashamed. On the other hand, knocking off long standing best practices from other industries is a good thing; let’s just not call it original. This industry is crying out for a simple, elegant, real Web 2.0 integrated PM, billing and EHR solution. Having used five different SaaS solutions and demoed everything else, we await Godot! The problem is two-fold. First, any solution one would bet on being around, has been around and, it shows, that includes companies like Athena or AdvancedMD that have built upon something over a decade old but are improvements over the even longer in the tooth software and big iron vendors. Second, more recent start-ups like Practice Fusion and Kareo while intriguing don’t scale and their capabilities are quite limiting. Rather than wish for standardization from the payer/regulatory/government side of the aisle, more muddle might just create the economics that compel organizations with an innovative technology pedigree into the space or a roomful of Stanford college kids living on ramen, that are up for the challenge. Until then, the ongoing gaggle of me-too providers will continue to “revolutionize” our industry by large press releases touting small process improvements and guarantees for which they deserve some credit but not our business.

  9. My nurses use check lists in assessing every ED patient. These are canned and not specific to each patients presentation. They follow checlists when then dicharge a patient. These checklists have dumbed down the nurse and added one hour to the average length of stay, as compared to the day prior to turning this monstrosity on. They have locked the nurses attention to the computer instead of to the patient or the doctor. Progress notes are now rare and meaningless. If it is not a box checked on the list, then it is not a concern of the nurse. In fact, the system has made the nurse unnecessary; the system only needs medical assistants who can enter data. The patient and the doc are on their own.

  10. Mr. Bush has a good point. Though some may think that his blog is an informercial, it does point to one of the major contributors to our poorly productive system. “Claims Processing” Though I fear the unintended consequences of a one payer system, it goes without saying that the greatest inefficiency in medicine is claims processing. As Mr. Bush states, there are 4 million reasons for a claim to be denied. It could be as simple as whether one insurer wants the hyphens in the social security number and another doesn’t. An absolute standard system that can only be brought about with one payer would save billions of dollars in money not spent on direct health care. Mr. Bush’s company’s primary business could be eliminated. There was a time when I could submit claims electronically directly to insurers with no middle man. Because insurers constantly change the formats of their claims, vendors could no longer keep up with the changes and this created another industry of clearinghouses and middle men siphoning more of the healthcare dollar. With one payer, I could eliminate outside sources like Athena and McKessen and save over $17000 a year in my small solo practice. This could afford me the opportunity to get an EMR that won’t talk to another EMR because there is no absolute uniform stand in this sector also. Ultimately, this is all talk. Who are we kidding? Money has to be spent in this economy. Listen to the people from Buffalo begging the government for jobs.

  11. Just an observation on this piece and many others on THCB: Is there anything more insufferable in the healthcare industry than a reflexively defensive doctor?

  12. Hi Mr. Bush,
    I certainly agree that there are many useful applications for checklists in health care. I do believe however, that the word ‘checklist’ tends to give people the impression that the process is being dumbed down. After all, McDonalds claims its success is based, in part, on its simplified checklists. Would it be better to refer to such processes as algorithms?
    Nurses and doctors are already accepting of such protocol with algorithms for life and death situations like ACLS and PALS.
    Checklists have been used successfully in the airline industry for years; just ask Capt. Sullenberger how important they were when landing his plane in the Hudson. No one would argue that such a checklist made him less effective. In fact, the American Nurses Association is in support of Just Culture, an approach to patient safety that employs a structured algorithm for analysis of certain events.
    As a nurse, my job is being made simpler everyday with the use of medication dispensing machines and trending software that does the thinking for us. This is not necessarily a good thing. Trusting such technology can make us lazy and complacent, as evidenced by the heparin overdose of three infants, including Dennis Quiad’s twins in 2007. As technology advances critical thinking and attention to detail recede. We need to find an effective balance between brainpower and protocol. A checklist that incorporates both will be an asset to health care.

  13. Checklists and cookbooks provide an illusion that the human body and its diseases are predictable with certainty. What is predictable is that the body and its diseases are non predictable.
    Checklists and medical cookbooks are good for bedside actors and physician wannabes. Checklists and medical cookbooks are good to remind the surgeon to scrub and put on gloves and call a time out, but hardly useful in treating a post operative patient with obtundation, fever, oliguria, without leuckocytosis.
    They are used for diagnosis: tattered middle age man walks in to his cookbooked and checklisted PCP with chief complaint of: “My friends state I look bad but I feel good.” Doc does not ask any questions but clicks on the app, the spanking new Luta Adnawag “Modern Medical Checklist and Cookbook” and starts searching. He reads and asks the patient: ” let’s see, looks bad and feels bad?”; “uhh, looks good feels bad?”; patient states that is not it. “ok, here it is, here it is, looks bad feels good.” Patient excitedly asks, “what is wrong, what does it say”. Doc states, “you are a —–a”

  14. Hi Bushy,
    The answer to your concern: Facsimiles transporting results are meaningfully safer and more efficacious than EMR medical data storage systems.
    They are safer because it is known immediately that a result has arrived and are more efficacious because they are looked at upon arrival. Results sent electronically to an EMR could sit there for days.
    I have hired an employee using the funds garnered from progress note generation and up coding by computer to scan EMRs for results coming in on hundreds of patients. Otherwise, I would never get them.

  15. That’s an infomercial, not a blogpost. Gawande wrote about checklists for better patient care – Bush writes about a pile of stuff, only some of it related to checklists … and most of it seems to be geared towards the bottomline.

  16. Sexy? You make health care sound very dull Mr Bush. Still welcome to the blogosphere and thanks for allowing us to repost on THCB so that we can all take potshots.
    Now please write something I disagree with, and bring your Falcon.