Doctors, Hospitals and the Yankees

Joe Boyd hated the Yankees.

“Those damn Yankees.  Why can’t we beat ‘em?”

Then he got the opportunity to save his beloved Washington Senators by making a deal with the devil – giving up his soul in exchange for being transformed into “Shoeless Joe” to propel his team to win the World Series.

Interesting.  I think a lot of doctors are making their deal with the devil.  They are looking for a small gain in comparison to a long-term of misery.  True, Joe Boyd made out in the end; but that will only happen if someone from Hollywood writes our script.

Here’s the problem: at the core of our problems with healthcare is the total lack of cohesive communication.  Doctors have no idea what other doctors have done with a patient.  Tests get ordered, medications get changed, procedures, hospitalizations, even surgeries are done without communication to other doctors who would benefit from this information.  The conduit of communication is this:

Doctor: “So, how have you been doing over the past few months?”

Patient: “Didn’t you get the notes from the hospital?  I was in for two weeks.  I had a heart attack and a stroke and now I am in rehab for both of these.”

Doctor: (checks chart uncomfortably) “No, I didn’t hear about it.  Why don’t you tell me about it….”

Situations like this happen daily at my office.  Patients are started on medications by specialists without my knowledge.  Lab tests are done that I have no access to.  Huge changes happen in the lives of the patients for whom I have cared for over a decade, and I get nothing.  Even consults I order are done without any communication back to me.  On the other side of things, my patients are hospitalized without any consideration of the care I have been giving over the past decade.  Patients are treated as if their care starts from scratch every time they enter a new venue.

It hurts my care for the patient.  It hurts the other doctors’ care for the patient. It hurts the patient.

And it costs a lot of money.  Disorganized, we cannot beat this behemoth of dollars spent.  Without good communication, communication that allows each person involved in the care of the patient to see exactly what is going on with the patient, the spending continues.

So what can be done about it?  How can the care of the patient be organized?  One common solution is the Integrated Delivery Network, or IDN.  An IDN is a network of doctors linked together through a hospital.  The care is integrated through a common record, or at least through a conduit that eases the flow of the patient from point of care to point of care.  Academic medical institutions are IDN’s as are many private hospitals (such as Kaiser – although Kaiser operates as its own insurance carrier as well).  This seems to make sense.  It breaks down barriers of communication and improves care.

But there’s a catch: the hospital.  Hospitals are often thought of as being on the same side as doctors – after all, doctors work for hospitals, right?  While this is somewhat true for specialty physicians, many of whom make their revenue from procedures done on hospitalized patients, it is not true of primary care physicians.  Hospitals are centers of care, yes, but they are also centers of spending.  A hospital is not motivated to save patients money.  Their profit is driven by patients being sick, getting tests and procedures done, and racking up cost.  A patient can spend in a day in the hospital more than they will spend in a lifetime at my office.  In this situation, the patient is treated as a commodity – something to use for a profit.

Does the hospital want me to be responsible, not ordering unnecessary tests, keeping patients healthy and out of the hospital?  Do hospitals want me to get patients in hospice at the end of their lives, eliminating unnecessary hospital stays?  Do hospitals want me to keep patients out of the ER?  They won’t get mad at me if I am the only one doing it, but all doctors getting responsible would be bad news for their bottom line.  Selling myself with a hospital will put me in a conflicted position: wanting to please my employer, yet wanting to do what’s best for the patient.  In this way, IDN’s are fatally flawed.

So what can be done?  How can communication be fixed without letting the hub of the communication network be a source of spending?  Think back to the conversation I recounted above.  Who was the hub in that setting?  The patient.  Perhaps we should consider this model when moving toward a communication network.  Perhaps a patient-centered communication model would optimize communication without raising cost.  After all, shouldn’t I answer to the patient – the one who is spending the money and the one who receives the care – for the decisions I make?

What if we set up a decentralized communication network that was linked not by doctors, hospitals, or insurance companies, but by permissions given by a patient?  Here’s what I mean:

  • I would have access to any records on the patient on any clinical database that the patient allowed me access to.  Instead of importing labs into my system, I would have access to the laboratory’s system for any patient I had permission from.  That way if the patient had labs done by another clinician, I could see the results.  If the patient was at the hospital, I would have access to those records as well.
  • I would give access to any clinician who was given permission by the patient to see my records.  If the patient was in the emergency room or in the hospital, the doctors there could see what I have been doing with the patient in the outpatient setting.  If a consultant wondered why I ordered a consult they would have easy access to my documentation of this.

Sounds risky?  I think it is less risky than a centralized database with all the information in one location.  Sounds hard? Isn’t what I described just a description of what the internet is?  Information on my blog is not downloaded on your computer, you just have access to it.  If I wanted to deny access, I could.  If I wanted to limit that access, I could do that as well.

This is exactly what happens with banks as well.  The consumer has control over access to bank accounts.  If they want to allow their gas company to draft from their checking account every month, they can.  They are not required to gather all of the banking information in one location, it is spread out among many.

In baseball, often it is the team who spends the most money who wins in the end.  Those of us who grew up hating the Yankees can attest to that ugly fact.  Healthcare is presently run by those who control the money: the insurance companies and the drug companies.  They win because we can’t afford to fight them.  They win because the minute they get behind, they find a way to use their money to get back on top.  But we don’t beat such spending by selling ourselves to fix our short-term problems.

To fix this problem, we don’t need more of the same.  We need the whole way the system is set-up to change.  We need the rules to change.  We need a change in ownership.

Dare we admit that the real answer to our problems is in the hands of our Washington Senators?

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

5 replies »

  1. How dare you imply that Hospitalists are less than perfect. Don’t you know it’s the fastest growing speciality in the history of medicine? And that all hospitalists know way more than you and they don’t need your input or the echo you had done just last week, they will just order another one. And repeat a couple of normal MRI’s and consult every conceivable specialist and then send the patient back to your office sicker than when they went in, on medications they have already failed all the while patting themselves on the back for what a good job they do – no, make that GREAT job they do. Because it really isn’t about saving money, is it? And it’s certainly not about caring for patients properly or well. There is that new fangled communication device called the telephone but somehow hospitalists don’t know how to use it except to call another consultant but certainly not the primary care doctor who has been seeing the patient for years. And if anyone says anything about, “social rounds”, you will see the top of my freaking head blow off and I will post the video on the Internet! When a hospitalist says social rounds to a primary care doctor it’s like using the worst ethnic slur imaginable, the most cutting of insults that you are not a professional but you are welcome to visit and maybe fluff the pillow. BTW, I see all my own patients at my local hospital but occasionally they get admitted to another hospital that is close but where I don’t have privileges. And that is how I know about hospitalists.

  2. Rob,
    This is a good post with the problem re-framed very well. Of course, what we really need is collaboration among healthcare organizations; as well as individual doctors.
    One way to improve healthcare operational management function is to obtain better information by collaborating with other organizations in gathering information. Why? Most operational failures result from breakdowns in the supply of materials and especially patient information across organizational boundaries. Better capacity decisions can often be made in collaboration with other institutions.
    For example, emergency rooms often take collaborative approaches and use Internet technology to regulate ambulance traffic to emergency rooms. Some metropolitan areas share information concerning accessibility and efficiency of care on a regular basis. The sharing of information facilitates benchmarking that leads to improved performance for the patient and community.
    Hospitals can also benefit from involvement in community-based quality improvement initiatives. For example, community hospitals can collaborate with their competitors and members of the business community to share information that leads to the identification of opportunities to improve performance, the delivery of root-cause analysis, and the development of process measures that facilitate change.
    Working with other organizations and employers in the community can not only lower costs, but also improve population health.
    Dr. David Edward Marcinko; MBA, CMP
    [Atlanta, Georgia, USA]

  3. What you describe is a distributed peer-to-peer network and is very similar to the way the Internet is organized.
    I personally feel that this is the best way to give access to individual health information. However, the government is launching many “health information exchanges” which will create walled gardens and a tower of babel… not a good solution.
    Fortunately, part of “meaningful use” is to mandate that patient records be provided in a standard format (the “blue button”). If this is implemented, it would be relatively easy to put together the distributed peer-to-peer network and bypass the HIEs.