Last week I attended a conference on health policy at the University of Chicago, where I moderated a panel that examined implementation of the Affordable Care Act. For much of our time, the panel focused on Accountable Care Organizations. Panelists and attendees wondered whether ACOs would meet the same fate as Integrated Delivery Systems of the 1990s. Some in the audience mentioned that when it comes to integration, electronic medical records could be a game changer. EMRs could be used to monitor and reward cost saving decision making, for example. But most ACOs are still figuring out how to use EMRs for clinical decision making; their use in helping managerial decision making remains far off.
As more and more speakers expressed skepticism about the future of ACOs, a physician in the audience offered a truly fresh perspective, one that makes me feel much more optimistic. I never learned this physician’s name, so I will call him Dr. Yes. Before I summarize Dr. Yes’ argument, it is helpful to turn back the clock to the late 1990s, when IDSs were taking the health industry by storm. Perhaps the defining feature of IDSs in the 1990s was the integration of hospitals and primary care physician practices. This strategy failed in large part due to classic agency problems. In a nutshell, an agency relationship can fail because of incentive problems (the principal is unable to effectively motivate the agent) or selection problems (the principal employs the wrong type of agent.) IDSs suffered both. When hospitals acquired physician practices, they converted entrepreneurs into employees who resisted any kind of incentive payments. As employees, primary care physicians did not work as hard or show as much commitment to their practices. Moreover, those physicians most eager to give up their autonomy were those looking to dial down their practices and lead the “quiet life.” In these ways, IDSs experienced both incentive and selection problems, with devastating results.
As both the private and public sector aggressively shift healthcare incentives from a “do more, bill more” to a value and outcome based model, healthcare providers ignore patients role in driving outcomes at their own peril. It is generally understood that patients forget 80-90% of what they are told at the doctor’s office. As incentives no longer reward outcome over activity, this is a disaster financially for health professionals. This will require healthcare leaders to think in a different way. One has to be in denial to think that healthcare reimbursement isn’t entering a deflationary period yet it’s not all doom and gloom for forward-looking healthcare organizations. In fact, it’s a massive opportunity to leapfrog competitors.
As the founder of the Institute for Healthcare Improvement, Dr. Don Berwick stated in an earlier piece:
“The health care encounter as a face-to-face visit is a dinosaur. More exactly, it is a form of relationship of immense and irreplaceable value to a few of the people we seek to help, and these few have their access severely curtailed by the use of visits to meet the needs of many, whose needs could be better met through other kinds of encounters.”
Smart Doctors Recognize Their Inefficiency
If one were to observe a doctor for a month, you would find that doctors have their own FAQ for various conditions, diseases, prescriptions, etc. They are essentially hitting the Replay button hundreds of times a month. Smart doctors are recognizing that there is a better way. The patient and family benefits greatly when the doctor has a mini package of curated content (video, articles, etc.) that is developed for the patients. This is predominantly a manual process today (e.g., writing down web addresses in an appointment or emailing them afterwards).
The electronic medical record (EMR) is here to stay. Its adoption was initially slow, but over the past decade those hospitals that do not already have it are making plans for implementing it. On the whole this represents progress: the EMR has the ability to greatly improve patient care. Physicians, as well as all other caregivers, no longer have to puzzle over barely legible handwritten notes or flip through pages and pages of a patient’s paper chart to find important information.
With the EMR, it is easy to see what medications a patient is taking, when they were started, and when they were stopped. Physicians can easily find key vital signs – temperature, pulse, respirations, and blood pressure – plotted over any time frame they wish. All the past laboratory data are displayed succinctly. But it is not all gravy.
There is a Problem
I use the EMR every day, and I am old enough to have trained and practiced when everything was on paper. While overall, I am happy to have electronic records, there is a problem: The EMR is trying to serve too many masters. The needs of these various masters are different, and sometimes they are incompatible, even hostile to one another. These masters include other caregivers, the agencies paying for the care, and those interested in medico-legal aspects of care. What can happen, and I have seen it many times, is that the needs of the caregivers take a back seat to the needs of the payers and the lawyers. The EMR is supposed to improve patient care, but sometimes it makes it worse. Physician progress notes illustrate how this happens.
There’s a (tiny) bit of a discussion going on in Twitter about a post I wrote responding to Vinod Khosla’s statement that 80% of the work that doctors do will one day be replaced by computer algorithms.
In my post, I talked a bit about the marketplace-driven IT innovations in healthcare, and medicine as seen through the eyes of the IT entrepeneurs. I questioned just how much of what doctors do today can really be replaced by algorithms, particularly the doctor-patient relationship.
I then asked if Khosla was right and answered myself – Maybe. I stated that we were in the midst of a huge disruption in healthcare, and reflected on how I was already seeing signs of that disruption in my current practice. And while I still did not see anything changing too much just yet, as far as the future Khosla predicted? I wasn’t so sure.
I then stated that if there is a revolution in healthcare, we docs needed to make ourselves a part of it now. I urged my fellow physicians to become involved, in order to be sure that what happens in the IT-driven healthcare future actually improves our patients’ health beyond what we are doing today.
It’s a completely legitimate concern, and, I believe, an extremely important one. As an example, I cited the evolution of the EMR – a system that has created high hopes and caused huge disruption at enormous cost, even as we continue to struggle to find conclusive evidence that EMR use actually improves patient outcomes.
Probably the hardest part of making the change from a traditional to a direct-care practice is the effect it has on relationships. I am only taking a maximum of 1000 patients (less at the start) and will be no longer accepting insurance. These changes make it impossible for me to continue in a doctor-patient relationship with most of my patients.
For some, this transition will be more hassle than anything. Some people do everything they can to avoid my office, and so are not going to be greatly affected by my absence. They will simply choose another provider in our office and continue avoidance as always. There are others who see me as their doctor, but they haven’t built a strong bond with me (despite my charm), so the change may even be a welcome relief, or a chance to avoid initiating the change to another doctor.
But there are many people, some of which have already expressed this, for whom my departure will be traumatic. ”Nobody else knows me or understands me like you do,” one person told me this week. ”I’ve seen you for so many years, you just know so much more about me than any other doctor,” said another. I’ve seen tears, have gotten hugs, and get frequent demands for a clearer explanation as to what I am doing and why. It’s been a rough week for me, as I don’t feel I can cut off these relationships without some sort of closure. Fore someone who sometimes goes overboard in the importance of others not being mad, it’s been hell.
I recently viewed health care through the lenses of a technology entrepreneur by attending the Health Innovation Summit hosted by Rock Health in San Francisco. As a practicing primary care doctor, I was inspired to hear from Andy Grove, former CEO of Intel, listen to Thomas Goetz, executive editor of Wired magazine, and Dr. Tom Lee, founder of One Medical Group as well as ePocrates.
Not surprising, the most fascinating person, was the keynote speaker, Vinod Khosla, co-founder of Sun Microsystems as well as a partner in a couple venture capital firms.
“Health care is like witchcraft and just based on tradition.”
Entrepreneurs need to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists.
Health care must be more data driven and about wellness, not sick care.
Eighty percent of doctors could be replaced by machines.
Khosla assured the audience that being part of the health care system was a burden and disadvantage. To disrupt health care, entrepreneurs do not need to be part of the system or status quo. He cited the example of CEO Jack Dorsey of Square (a wireless payment system allowing anyone to accept credit cards rather than setup a more costly corporate account with Visa / MasterCard) who reflected in a Wired magazine article that the ability to disrupt the electronic payment system which had stymied others for years was because of the 250 employees at Square, only 5 ever worked in that industry.
There was no mistake, but a bad thing has happened. Despite the best efforts of the doctors, Bob’s wife is very sick. Due to a rare side effect of treatment, her liver is failing. Bob believes this could have been prevented. He is very mad.
“When we go to see the doctor, he stares at the computer,” says Bob. “He does not look at us. Most of the time, the doctor is not even listening to us. He just sits there typing at the keyboard, gaping at the screen. If he had been listening when my wife talked about the pain, then he would have stopped the drug. Then her liver would be fine. She would be OK. All you doctors have become nothing but computers.”
Now here it gets interesting. After I listened carefully to Bob and sat with him at his wife’s bedside, I decided to check “the computer.” There in the doctor’s records I saw a long discussion and analysis of the problem with her liver. Quite opposite of ignoring her, her doctor had listened, had changed therapy and was watching her liver carefully. Sadly, despite the change, her liver had gotten worse. The problem therefore, was not that the doctor was not listening. He definitely was. The problem was that the computer had stopped him from communicating.
It is strange to think that a system of information and data exchange, which allows you to communicate with anyone around the entire world, interferers with connecting to the person right in front of you. We see it constantly as cell phones, Ipads, computers and even that “old” obstructer the television, get between us. At the time we need to communicate most desperately, electronics can block that most human connection of all, the physician – patient relationship.
In the current issue of The New Yorker, surgeon Atul Gawande provocatively suggests that medicine needs to become more like The Cheesecake Factory – more standardized, better quality control, with a touch of room for slight customization and innovation.
The basic premise, of course, isn’t new, and seems closely aligned with what I’ve heard articulated from a range of policy experts (such as Arnold Milstein) and management experts (such as Clayton Christensen, specifically in his book The Innovator’s Prescription).
The core of the argument is this: the traditional idea that your doctor is an expert who knows what’s best for you is likely wrong, and is both dangerous and costly. Instead, for most conditions, there are a clear set of guidelines, perhaps even algorithms, that should guide care, and by not following these pathways, patients are subjected to what amounts to arbitrary, whimsical care that in many cases is unnecessary and sometimes even harmful – and often with the best of intentions.
According to this view, the goal of medicine should be to standardize where possible, to the point where something like 90% of all care can be managed by algorithms – ideally, according to many, not requiring a physician’s involvement at all (most care would be administered by lower-cost providers). A small number of physicians still would be required for the difficult cases – and to develop new algorithms.
News organizations used Dr. Judah Folkman’s death to report on his decades-long cancer research career. Given his status as a distant, non-celebrity, non-Nobel surgeon, you may be asking yourself why you, personally, should care about his death. Here’s why.
We were in our second year of medical school, feeling the growing pressure of clinical years just around the corner, when we would be thrown into the hospital system. For now, we had lectures in a large hall with 130 students sitting in chairs that sloped down to a stage. Professors came with presentations and handouts and complex diagrams. The immunology lectures were continuous strings of letters and numbers, with only the occasional verb, impossible to decode as human speech without months of training. Every tissue, every disease, every human physiologic function was discussed, down to the sub-molecular level. After hours of these lectures, the air would get stale and backs would ache and the squeak of weight shifting in chairs would become a metronomic beat marking out time that seemed to pass endlessly.
Then, one day, Dr. Folkman walked on stage. He asked us to put down our pens. He said he was going to teach us something that no one else would ever discuss, much less teach. I can’t imagine what he was thinking as he looked out on the sea of our faces. Give or take a few years, almost all of us were twenty-four years old. Almost all of us were single, ambitious, untouched by any of the major human experiences—no children, tragedies, severe illnesses or grief. The youth, the arrogance, the lack of world experience, all of it had to be a daunting, uninspiring sight. Dr. Folkman knew that in mere months, we would be keepers of information that would profoundly change lives. Pathology reports, cancer diagnoses, even the death of a loved one, those were all things we would be telling vulnerable people. Our actions and our words would be often unsupervised, particularly when disaster struck in the middle of the night.
Don’t assume anything.
Assumptions can kill.
Assuming something regarding your own health care can cost you money, cause you pain, and yes, even kill you. Here’s my list of potentially harmful assumptions:
1. No news is good news
If you have a test done and don’t hear anything about the result, do not assume it is fine. This assumption kills people. I have too many patients with too much information flying at me every day for me to catch every important detail. Sometimes things are missed, but sometimes the results don’t come to our office. We have trained our patients to expect an email or letter with their results within a certain amount of time, so they sometimes call when the test results don’t come in. I tell them to do so in the clinical summary sheet I hand out at the end of each visit, but the assumption remains.