Healthcare at the Crossroads or in the Crosshairs?

This week a number of ‘experts’ in healthcare policy met as part of the President’s plan to reform healthcare within the next year. One of the reasons that Pliny has been a bit slow to post over the last few weeks is that I am involved in the healthcare reform movement and have been busily trying to get some relevant information in front of those people in Washington. As a fighter in this particular war for more than 20 years some of what I am hearing from them is good, potentially great in fact - some not so much. But for the first time in my career policy wonks are starting to say the right things. The challenge will be to prevent greed, ignorance or ego to derail this process. If things go terribly wrong, the 40 billion dollars to be spent on medical infrastructure will simply go to entrenching the existing records systems which contribute to the problems and which compete against the systems that hold true promise.

What good have I been hearing? Three things mainly: 1) we need to change the way care is delivered and by whom, 2) advanced Information Technology needs to be developed to support reforms, and 3) existing electronic health records aren’t the answer to 2. Now if we can just keep them on track and not allow the economic Philistines who will see this as the biggest land grab at least since Iraqi no-bid contracts from dominating the field. If we do, within five years the USA will have the most advanced healthcare delivery system in the world and it may be possible to obtain it at half the cost we spend today. That is not a pipe dream.

For 15 years I have been telling anyone who will listen that healthcare reform is not about changing how we pay for services - it’s about changing the way the care is delivered in the first place. Now, for the first time, these same words are coming from the President of the AMA, and both sides of the Congressional aisle. They don’t agree on what that means or even where to start, but that is a huge positive shift in thinking. Why is that so important? One reason is because the changes in the payment structure (especially on the federal side) has contributed greatly to the cost problems we face now. Money gets shifted around kind of like the deck chairs on the Titanic but nothing is done to address how care is best delivered- and by whom... or what... The larger answer is frankly that we don’t have a healthcare system: we have an acute and emergency care system. And even that isn’t nearly as good as it could be.

Nuts and Bolts of Medical Care

The diagram below is a somewhat simplified representation of the problem faced by clinicians caring for patients. This is the diagnostic and management curve. It represents the fact that there is a continuum of complexity in medical conditions. On the left are a few conditions either so simple or benign that anyone can deal with them and as we move to the right, the conditions become harder and harder to either diagnose in the first place or manage once they are identified. Some are darn near impossible to recognize. Most conditions are clustered somewhere in the middle.

Figure 2 below reveals something we don’t often talk about but which is true none the less. We tend to think (or hope) that all physicians are pretty close in their abilities. That’s no more true in medicine that is in anywhere else in life. There is great variability in skill. (There’s an old doctor joke; “Question: what do you call the guy with the lowest passing grades in medical school? Answer: Doctor...”) Some a superstars and some are dogs - and it’s often hard for patients and even some colleagues to tell the difference.

The next diagram shows why we need to care. The area between the best and the worst represents missed or delayed diagnoses, sub-optimal care, excessive testing and unnecessary costs. Variability in experience and skill results in a wide range of inefficient approaches to even common problems because everybody has their own way of doing things - regardless of whether or not it really is the best way. This variability is not only costly but it hampers our ability to collect rational data on diagnosis and therapy to see what works and what doesn’t. There’s so much static in the data it’s hard to make sense of it. And patients suffer as a result.

If everybody operated at the level of our best and brightest, then patients would get better care and costs would go down. Why? Optimal care is the cheapest care around. Conditions recognized sooner are easier to treat and success is higher. Optimal care results in fewer complications, less missed work, longer life, you name it. Optimal care is a relative bargain. Or at least it’s a justifiable expense.

How do we achieve optimal care?

People have been working on that one for decades with mixed results, but there are some things in the wings which may break this problem wide open. You no doubt have heard lots of politicos talking about evidence-based medicine - using standardized approaches to problems based upon the best available literature and a consensus of experts. Sounds great. Only problem is that people don’t use it. Take for example the most common cause of death in the USA - heart attacks. There is abundant literature and agreement on many aspects of caring for such patients. Best practice standards are readily available. One simple recommendation is an aspirin for the patient unless contraindicated. An aspirin tablet for the most common killer. Not too hard right? Wrong. Even here only about 90-93% of heart attack victims who qualify, get an aspirin.
And if our healthcare system can’t even get that done 100% of the time, what do you think happens with all the less common killers? To be fair there’s a lot of stuff to remember in medicine - especially when you are tired, overworked, distracted, stressed, you name it. There is just too much knowledge for us to reasonably expect a person to remember it.

So what do we do?

Give up. That’s right, you read that. I said give up. Clinicians cannot be expected to manage the volumes of data and knowledge needed to care for their patients. It is not humanly possible. But it may be inhumanly possible.

President Obama’s call for advanced IT systems.

The President has been counseled to support research into the creation of advanced information systems to help clinicians get a handle on all of this. Last year a group well known experts in medical IT wrote a paper trying to spur R+D into perfecting such a system. They proposed 10 ideals for it. Strangely, one system already existed that had 9 of the ten already and had three more even more advanced features that they had omitted or not considered. This system has been quietly operating under the radar in clinical trials in two states. It is nearing completion of its second phase trials even now. On May 11 of this year, this system will be unveiled to a group of researchers at the National Science Foundation. Keep your fingers crossed sports fans because you ain’t seen nothing yet.

As advanced as some of the new systems are, there is a very real chance that we may never see then in practice, or at least not for many years. Why? Because of the political and economic power of the companies that sell existing medical IT - the electronic health record vendors (EHR). EHR’s are the current crop of digital record keeping systems that are in most hospitals and some clinics. EHR’s are the vile offspring of computer system that were aimed at billing and coding of medical services and like any evolutionary system their ancestry limits their potential. They are primarily record keeping systems - big incredibly, expensive, time consuming record keeping systems.

There is no doubt that using EHR’s increases the amount of data stored on a patient compared to the days when all data was hand written into notes. It’s easier to read too. The problem is that all data is not information - at least not from the standpoint of relevancy. For the purposes of this conversation when I refer to information I mean relevant data - data which has current value in assessing a situation. When I refer to knowledge I mean recognizing key patterns within the relevant information that synthesize the information into a meaningful understanding of the situation and can lead to a reasonable set of actions. Increasing the amount of non-relevant data can increase the volume of static within the decision environment. It’s a classic signal to noise problem. The more non-relevant data that exists the harder it is to sort through it to find the nuggets (or patterns) vital to synthesizing knowledge.

The marginal clinical benefits of electronic records as they currently exist were realized in the 1980‘s when the first systems came into being that allowed clinicians to review patient data from a location other than the patient’s ward, could read their colleagues type-written notes (removing the legibility problem) and could enter orders remotely. To this day, one of the best systems I ever encountered was a custom installation created in the 1980‘s under the guidance of a forward thinking physician at Methodist Hospital in Indianapolis. It was simple, it was quick and it was easy but provided all the benefits described above. The systems that have replaced it are why have EHR’s gained a foothold into hospitals? Hospitals love EHR’s because they increase charge capture, reduce data storage challenges and transfer administrative burdens to the clinicians.

A common claim is that EHR’s improve patient safety - a claim most commonly promoted by non-physicians selling EHR’s. Just how much is safety improved? Let me share an experience with you. While working at a local hospital I was required (at my own expense of course) to be trained for several hours in the use of one of the popular EHR brands which had just implemented a 100 million dollar installation (no the numbers are correct). Touted as an aid to improved patient safety, I decided to try a little experiment, during our practice time, to see how smart the system was. I went to the order entry screen and ordered an anti-hypertensive medication for the practice patient. Instead of a typical dose of say 20 mg twice a day, I entered a dose of 200 mg twice a day - enough to kill the patient. The system accepted the order without comment. So I upped the dose to 2000 mg. Still no response. I ended up ordering 200,000,000 mg twice a day. That’s a dose of 400 kilograms of a drug per day. The 100 million dollar EHR accepted the order without comment. Not exactly a confidence builder that. I mentioned this to the trainer and they assured me that the pharmacist would have caught the error. Now firmly entrenched in my Colombo mode, I said that ‘My wife says I’m really dense, but the pharmacist already reviews my orders for errors and it didn’t cost us 100 million dollars.

Go to any modern hospital with an EHR system in place what you are likely to see is a bunch of clinical people huddled around computer terminals entering volumes of data most of which is to satisfy somebody’s compliance policies or capture charges. Even the lists of medical problems on the patient is stored not in a clinically relevant format but in the billing format. And all that terminal time is time away from the bedside - not a good trade off. And if the vendors have their way, all the medical stimulus money will go to install more of these bloated systems that do not improve medical care or increase our access to it. These systems definitely change how medicine is practiced but not in a good way.

Is there any alternative. Yes there is, and its name is MIKE. When I get back around to medical topics, I’ll introduce you to MIKE. And discuss how MIKE is changing that knowledge curve we talked about to something like this...


pboyfloyd said...

Yep, anything with the word 'medical' on it means $$$$$$.

Emma just got a wheelchair. The cushion costs $900. Get that? The CUSHION for the damn thing costs nine hundred bucks!

Now, the entire thing has less engineering in it than a hundred dollar bicycle from a mega-store!

Pliny, I really sympathize with your cause, but I don't think that you are going to be able to root out the money grubbers, they are ENTRENCHED and NOBODY is going to be losing their jobs.

I hope I'm wrong.

Stacy said...

Ugh! Thank you for taking the time to try and explain this whole mess.

Harvey said...


I guess from your recent post that you are a physician (as I am, Otolaryngologist). Here at the end of my career, I am daily trying to use one of these "information" systems. Although it has all of the characteristics you describe, the trade off for the improved access to patient information (and charge capture) is that it significantly reduces the number of patients I can see in my office as outpatients. Indirectly, this increases healthcare costs in that I must spend more of my clinic time doing what amounts to clerical work (i.e typing in my notes and other patient information) that I used to be able to dictate or depend upon a considerably less expensive individual to enter in the record. One hopes that this new breakthrough system you describe will be able to take these factors into account.

Pliny-the-in-Between said...

Harvey, Yes I am guilty as charged.

Your experience sadly typifies all of our experiences with EHR systems. We end up spending more time with the doggone computer screens than we do with patients. Not a good trade off. The new systems I'm describing were designed by MD's to integrate into a clinical decision-making work flow. They do the practice management activities behind the scenes. So far in testing, they have not slowed things down, while offering some significant improvements. We'll see, but the initial work is very promising. The challenge will be to get clinicians to tolerate one more change, even if it's a good one.

Pliny-the-in-Between said...

Also - you mentioned using less expensive people to manage some of your data historically. This prototype system was designed to do that and in fact extends that capability much farther. More on this in a later post.

Harvey said...


I also suspect from some of your predictions about this "new" system that it will make much greater use of "pysician extenders" like PA's and advanced practice nurses, who can often intervene in the overall provision of healthcare more efficiently and with at least acceptable quality of care at a considerably lesser direct cost. This then, if true, always raises the specter of much more stringent control of individual patient's access to what they perceive as "good" quality care and or specialty level management of what is always, to the individual, an urgent or "serious" problem (in my experience). Carried to its logical conclusion, there appears to be no way to achieve "universal" haelth care without strict rationing of access and stringent limitations and rigid control over medical decision making (i.e. regarding tests or treatment regimens that may be permitted in individual cases). In fact, all of these parameters can be observed in previous experiments in socialized medicine.
One might think I am opposed (as a physician) to much of what this will entail. However, even though I will regret mightily the interference that such a system will impose on the traditional physician/patient relationship and even further force medical personnel to be "providers" with "clients" instead of treating patients, I can see no other way to improve the provision of medical care to an ever growing public without bankrupting the country.

Anonymous said...
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Anonymous said...

"I can see no other way to improve the provision of medical care to an ever growing public without bankrupting the country."

Harvey, Pliny, I had no idea it was that bad.


I have a question Pliny.

"For the purposes of this conversation when I refer to information I mean relevant data - data which has current value in assessing a situation. When I refer to knowledge I mean recognizing key patterns within the relevant information that synthesize the information into a meaningful understanding of the situation and can lead to a reasonable set of actions."

You seem to intimate that the new system would help with diagnosis. Did you, or am I reading too much into it?

Pliny-the-in-Between said...

OneBlood, These new systems assist with all types of medical decision-making from diagnosis to treatment and follow-up. That is one of the potential breakthroughs. Historically expert systems were limited to one particular type of decision or assistance. These new systems are not limited in that way. They are able to integrate information across the full spectrum of care in support of clinician's decisions.

Pliny-the-in-Between said...

Harvey - good comments. In my next post on this subject I hope to address your points and discuss how we may be able to avoid the pitfalls of previous national efforts. I actually believe it is possible to provide universal access, improve quality and slash costs at the same time. We'll see of course.