Chief information officers (CIOs) and chief medical information officers (CMIOs) have spent the better part of two decades on a quest for interoperability; yet, their Achilles heel lies in the “information” part of their titles. If information is the sole beacon of efficiency and value, the invaluable contours of human suffering, personal preferences and humanity itself are lost.
Information is the first step to developing knowledge and understanding, but what physicians and patients rely on in the real clinical setting, rife with changes, are knowledge, understanding and empathy. The cold, hard calculus of a=b does not always apply when dealing with people because they are much more complex and complicated than binary machines with screens. If it were so easy, there would be no problem reaching 100% compliance with medication or a plan of action.
Sadly, all data lives in a database; which might as well be called a wait-a-base; after all, the data just sits there and waits for someone to look at it.
The fundamental problem with today’s information architecture is that all data are not created equal. Data, information and knowledge degrade with each new doctor that becomes involved. In addition, systems design lacks an understanding of how the human computer works in the context of illness, anxiety or uncertainty. Healthcare is a people business in need of data, not a data business in need of people. Data are the means; people are the beginning and the end.
We need to design a system of health care that optimally meets the country’s needs while also being affordable and socially acceptable. Clinicians should be at the center of this debate if care delivery is to be designed in a way that puts quality of care before financial gain.
This challenge is too important to be left to politicians and policymakers. There is an urgent need for clinicians to step up, lead the debate and design a new future for health care. Placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be an ambition for all of us. We need to find the formula that meets the needs of the patients and communities we serve. A sincere collective effort by committed clinicians to design an effective system will lead to a health care system that has a democratic mandate and the appropriate focus on optimizing the outcomes patients and society need.
As clinicians enter the debate, they should keep three things in mind.
Promote the leadership role of clinicians
We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes. Cost effective care can and should be a byproduct of optimal care. Accomplishing this will provide a strong common purpose for efforts to address the challenges of designing outcome-based funding structures and improving access to care.
“Drugs don’t work in people who don’t take them.” C. Everett Koop, former US Surgeon General
Cost-based non-adherence, like any lack of medication adherence, leads to further complications and hospitalizations that could have been prevented. CMS appears to have recognized this when they announced that a new ACO measures on whether “providers have educated patients about the cost of medications” in the 2015 fee schedule. Cost and quality conversations between doctors and patients are becoming a cornerstone to value-based care.
The most expensive drugs are the ones that the patient never takes. Nearly one third of prescriptions go unfilled. When patients cannot afford a medication, and only discover the price or out-of-pocket cost at the prescription counter, it’s a big risk to long-term outcomes.
“It has been well established that a lack of affordability can drive a lack of adherence to a course of medications. Patients who do not take their medications cost the U.S. healthcare system an estimated $300 billion in avoidable medical spending annually due to poorer health, more frequent hospitalizations and a higher risk of mortality”, according to The Center for Health Value Innovation and the Network for Health Value in Innovation.
A lack of medication adherence drives further costs for the system and suffering for patients. Estimates are that more than a third of medicine-related hospitalizations happen because people did not take medicine as directed, leading to over 125,000 deaths.
Medication non-adherence, of course, can have many reasons: side effects, difficulty in administering the drug, and others, but there is clear evidence that cost is a factor driving non-adherence. 27% of Americans did not fulfill a prescription due to financial hardship in 2012 according to a Kaiser Family Survey. As copays, deductibles and out-of-pocket expenses go up, so, likely, will non-adherence, and value-based care, and value-based benefits must understand the costs related to non-adherence.
NPR ran a story recently about how some retailers are retooling efforts to appeal to consumers in light of increased competition, particularly from online vendors.
Many are striving to be more “customer friendly”; Kohl’s department store was mentioned for adopting a “no questions asked” return policy with the idea that customer loyalty could be enhanced as the retailer made itself easier to do business with.
Comparisons between health care and retail abound, and while we say it is ideal for the consumer experience to be the same in both industries, in fact they are much different. The gap between the two industries was well-illustrated in this video of a shopper in a grocery store. We see them at the counter having their items rung up. But they aren’t told the prices and when they are given the receipt at the end, they’re told the final amount due may actually differ from what they see on the receipt.
Let’s take the analogy a step further: what if the customer expected the same “no questions asked” return policy from Kohl’s? Or a money back guarantee? In health care, only recently has the federal government taken steps to impose financial penalties in instances of poor care (which is the health care system’s equivalent of a “return policy” from providers).
When our team was at Subimo we initially focused on cost and quality (outcomes) information on hospitals. It was clear that – for the same procedures – there were both low cost and high quality providers as well as high cost and poor quality providers. Our efforts with transparency were designed to help people sort through the information so they could make more informed decisions and understand what quality outcomes might mean to them. We knew there was much variation in outcomes with certain procedures (e.g. aortic aneurysm repair) and less variation with others (e.g. normal vaginal delivery). Helping people understand when a poor outcome was more likely to occur helped them with their decisions (and presumably made them better shoppers).