A Country Doctor Reads: May 19, 2019

“The physician–patient encounter is health care’s choke point” -NEJM

This week’s Journal has a very profound article about why healthcare has not evolved through its technology the way other sectors of society have.

My take, and extrapolation, is that there are three reasons why healthcare has failed to evolve in usefulness of both our product (the care we deliver) and our technology (our EMRs), our customer centeredness and the value/cost relationship of the services we provide.

1) Healthcare is not at all customer centered. Even the required operational framework for Patient Centered Medical Home recognition is completely top-down. We are being crushed by mandated screenings for everything from obesity to domestic abuse (see my postBrief is Good”). The whole notion of Quality is arbitrary and paternalistic. Cash practices are appearing and evolving to meet patients’ needs without the mandates of Medicare and the private insurance industry, but are in essence duplicating cost and effort because of Obamacare’s insurance mandate.

2) Our technology was not created with the purpose of speeding up or simplifying documentation so that clinicians can deliver better care. Instead, there was a dual focus of maximizing billing and controlling the “Quality” in clinician performance. Since we basically don’t have a clue, let alone agreement, about what Quality really is (see my 2009 postQuality or Conformity?”), any effort to promote or require Quality through templates and “hard stops” becomes cumbersome and potentially meaningless.

3) Healthcare is still practiced as if we were all solo practitioners without technology, seeing one patient at a time, in person, in the office, which is marginally more efficient than housecalls. So far, we have no incentives to do anything different. A silly example: A patient with perfect blood pressure at home on their internet connected sphygmomanometer doesn’t help my Quality ratings one iota, since my “grade” for the year is the last blood pressure recorded in the office for the calendar year (see my postDon’t Do Chronic Care in December”). And, as the NEJM article points out, there are no financial incentives to have nurses or other non-providers manage routine problems like hypertension in our current system.

Here is an eloquent section of the article by Asch, Nicholson and Berger:

“Information technology is changing medicine, but electronic health records (EHRs) are mostly demonized by clinicians, and the promised customer efficiencies seen in the retail, financial, entertainment, and travel industries have been largely absent in health care.

These approaches will improve with time. It’s worth noting, however, that the transformations seen in other industries have followed a different path. In these cases, aligned financial incentives, better customer centricity, and technology have been motivating and enabling forces for change, but the transformations themselves came from operational changes that enhanced productivity — mostly by finding ways to use fewer people.

The movement from bank tellers to automated teller machines to cashless digital transactions has reduced effort all around. Because of easy-to-use software, fewer people now use travel agents. Yet despite increased use of EHRs by clinicians and smartphones and wireless technology by patients, the fundamental approaches to managing hypertension, diabetes, and chronic lung disease have remained the same for 50 years. The drugs are better, but the way patients engage with doctors during office visits and hospital stays is unchanged.

The physician–patient encounter is health care’s choke point. So long as we continue to think of health care as a service that happens when patients connect with doctors, we shackle ourselves to a system in which increased patient needs must be met with more doctors. Other industries overcame similar constraints in various ways — McDonald’s pioneered a production-line approach to fast food, for example — but more recent transformations have come from facilitated self-service. Taxpayers abandoned tax preparers when TurboTax created a new pathway to what they wanted. Until we invent the TurboTax of health care, we won’t achieve the kind of productivity gains needed for transformative change in quality, access, or cost.”

https://www.nejm.org/doi/full/10.1056/NEJMp1817104

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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