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.