Wednesday, March 22, 2006
The Patient-Physician relationship as the fundamental basis for healthcare delivery is approaching the limits of its capacity. The Physician as the gatekeeper and source of health information and services has functioned admirably in this role throughout the course of history. As the volume of information continues to rise and the demand for that information and associated services also rises the ability of any individual Physician to meet that demand decreases. The point of diminishing returns is quickly drawing near. There are short-term solutions, but ultimately a new, expanded platform for delivering healthcare will be required.
The short-term solution is to augment the capabilities of the Physician to manage the vast amount of information within our Healthcare System. Health Information Technology (HIT) is expected to facilitate this process at multiple levels. It can occur at the national level with the National Health Information Network (NHIN) or regional level with Regional Health Information Organizations (RHIO). Locally hospitals can do this with the development of Electronic Health Records (EHR) and Physicians can also participate with PDA's and software products such as Epocrates. While these measures will be helpful to assist in the management of information and coordination of care, other measures will be needed to improve the delivery of services and decrease the cost of care.
Managing Quality & Cost
Quality care initiatives are already being implemented that will standardize "best practices", utilize HIT, develop process and transform healthcare cultures in an effort to improve outcomes. New market approaches to improve the delivery of healthcare through concierge services, and Intensivist extenders or to reduce costs for evaluating and treating minor health problems over the phone, through the internet or while shopping at a local store. Despite all this we still need a long-term solution. The greatest number of healthcare problems and the greatest cost to our Healthcare System is the direct and indirect result of chronic disease and preventable injury and illness. This is where the lever of the new healthcare delivery platform should exert its greatest force.
Health Information As A Core Part Of The Educational System
Health information education needs to become as essential as reading, writing and arithmetic. It is ridiculous to think that a seven minute encounter with a Physician once or twice a year is enough time to impart the collected wisdom and knowledge of our Healthcare System, nor is it enough time for the average person to grasp that information and incorporate it into their life. Health information education needs to begin as early in life as possible. It's a whole lot easier to treat someone who has spent a lifetime developing healthy habits than it is to try and reverse fifty years of hard living. We've come a long way in public healthcare policy from promoting personal hygiene to improvements in public sanitation. I think the next step is to take our vast knowledge of health information and introduce it as a core educational goal.
The Education System As Part Of The Healthcare Delivery Platform
Health information education can be developed alongside our existing educational system. The two main benefits would be to provide an infusion of resources into our current educational system and to develop a culture of healthy lifestyle in our society that will reduce the effects and cost of chronic disease in the future. The education will need three main components. The first is the teaching of a fundamental core of health information. This occurs throughout the K-12 grades. The type of information taught depends on the educational level of the student. The second part is an information management core. Part of this will include health information but it will also be necessary for students to learn how to access, evaluate and apply all kinds of information to their life including health information. The third part is a controversy core. There will, no doubt, be controversy on what type of information is taught as well as how to manage it. While we may not agree on what is delivered in the first two parts we should agree that acknowledging and debating these controversies should be a part of the educational process. Whether we like it or not, debate can be healthy, and controversy is a part of the massive information stream with which we contend. Future generations should be prepared for both of these as much as managing the massive amount of new health information they can expect as they learn to manage their health. Education today is a more cost-effective solution for the health problems of the future.
Sunday, March 19, 2006
This was the message of the cyborg collective known as The Borg in the television series Startrek: The Next Generation. It got me wondering if this is what the Healthcare System is really trying to say to Physicians? It also got me wondering if this is the message I'm sending in this blog at the expense of a more important message. I was reading one of Steve Beller's recent blogs on the importance of vision and found myself making the following comment:
"No individual, group, industry or nation is willing to undertake a journey if the destination appears no better than the point of origination."
This blog started as an attempt to better understand what is commonly referred to as our Healthcare Crisis. There are times when I appear to be leaving the impression that the future of Physicians is rather bleak. This is not my intention. I've come to realize that I must focus my attention on a vision of the future of healthcare that is not only more promising for our society but also attractive to Physicians.
Back To The Beginning
The position I've taken in this blog is that what we see as a Healthcare Crisis is a paradigm shift that is affecting the way healthcare is delivered. This crisis is best seen as the physical, psychological, social, economic, and cultural manifestations produced as we transition from an older, traditional model for delivering healthcare to an emerging, newer model for delivering healthcare. The platform for delivering healthcare in the traditional model was based primarily on the Patient-Physician relationship. The hypothesis discussed in this blog is that this fundamental relationship is being challenged and will be replaced. The new model will be based the Patient-Information Technology Interface. The Physician's primary role as a gatekeeper to the Healthcare System and its wealth of information and services is at the heart of what is being challenged. Nobody looks forward to losing their job and unfortunately this is a point I have emphasized to the detriment of the vision I see for Physicians in the future of the Healthcare System.
E Pluribus Unum
We tend to see the Healthcare System as a monolithic entity but it is really a complex-adaptive system. It is made up of multiple entities each of which is constantly adapting to the changes produced by their collective interactions. Physicians as a group are one of those entities but can be also by seen as individuals each with their own unique set of skills and talents. They will continue to adapt those skills and talents but will also need to have a vision of what role they will play in the future before they will consider relinquishing their role in the present. The growth of information available in our current Healthcare System has put Physicians at a disadvantage for being the gatekeeper and source of all that information. Having this wealth of information is one of the greatest strengths of our Healthcare System, but due to the volume of it, managing it is an impossible task for any one person. I think Physicians will continue to be a source of information and services but will be one of many sources.
There Has Got To Be A Better Way
As our Healthcare System increases in complexity, patients will depend more and more on Artificial Intelligence and Information Technology to act as both gatekeeper and a primary source of information and services. While this may appear threatening to Physicians I think it will ultimately be liberating. In the early days of medicine Interns were called upon to perform many of the relatively easy and mundane aspects of healthcare services such as drawing blood and transporting patients. This became known as SCUT (a.k.a. Some Clinically Useful Training). What a load of crap. It was cheap labor for the hospitals. As hospitals began to hire phlebotomists and transporters this freed up the Interns and Residents to focus on the more complex and important skills they needed to practice medicine. That is what I think Information Technology will do for future Physicians.
Seeing A Better Future Begins With A Better Vision Now
Too much of a Physicians time is spent doing related but not medically necessary work such as documentation, arguing with third party payers, and filling out an endless stream of various forms for insurance companies. Why we continue to fight to maintain this system is becoming the new eighth wonder of the world. Resistance may be futile but no one is expecting us to become cyborgs. We're not going to stop thinking because we have more Health Information Technology. We're going to become better at taking care of patients. They don't need the least of our skills and talent, they need the best of our skills and talents. The Healthcare System I want to be a part of in the future is one that both utilizes those skills and talents and values them. That is the vision we need to create because without it there will continue to be resistance.
Wednesday, March 15, 2006
Doctors are the result of a finely tuned selection process. Students applying for medical school are chosen based on the type of Physicians we anticipate they will need to become. It doesn't say this anywhere on the application but it is implied nonetheless. We look at today's Healthcare System and choose students who will have the best fit for it. Traditionally this system uses a combination of GPA, MCAT scores, personal statement, interviews and completing the pre-requisites for medical school. This system has worked well for the traditional, established model for delivering healthcare but what will happen if our healthcare crisis is really the sign of an emerging, new model for delivering healthcare? Are Physicians already trained in a traditional model of healthcare as capable of selecting future Physicians who will practice in an environment where an emerging, new model of healthcare is evolving?
The traditional model of healthcare is, in my view, a legacy system. The expression "legacy system" has been used in the computer industry and has been defined by some as "any information system that resists change." Others have described it as "inflexible", "difficult to integrate" and costly to maintain. In a recent description in Wikipedia the characteristics of a legacy system consist of the following:
1) "Large, monolithic, complex"
2) "Requires close to 100% availability"
3) "The way the system works is not understood"
4) "The user expects that the system can easily be replaced when this becomes necessary."
5) "The owner sees no reason for changing it."
With the exception of this last characteristic, it appears that, by all accounts, referring to the traditional model of healthcare as a legacy system is on target. Legacy systems don't show up overnight. They develop and mature over a relatively long period of time. They become very good at producing a product or delivering a service, but as they mature they reach a point of diminishing returns. This is what makes them vulnerable to disruptive innovation.
Sustainers Aren't Disrupters & Disrupters Are Sustainers
In Clayton Christensen's recent book Seeing What's Next he discusses innovation in the context of healthcare and states, "Improving the lives of people suffering from debilitating diseases is certainly a good thing. But it will not transform the healthcare industry into one characterized by affordability, convenience, and effectiveness. These things come through disruption." One of the things that makes legacy systems good at what they do is sustaining innovation, particularly the kind that sustains the legacy system. How they do that is to recruit people who are very good at sustaining innovation. People who are very good at sustaining innovation and who blend well with legacy systems tend to not be very good at disruptive innovation. They weren't recruited for their disruptive innovation skills, they were recruited for their sustaining innovation skills. So what does this mean for the future of healthcare?
Resistance to Disruptive Innovation
If our current model for delivering healthcare is a legacy system then the people who make up its core of human resources are committed to sustaining that system. These same people are also charged with recruiting the future human resources. This means our future Doctors. Based on this I predict that any innovation that is disruptive in nature is more likely to come from outside the traditional resources. Any disruptive innovation that improves "affordability, convenience, and effectiveness" risks resistance from those within the legacy system (like Physicians) particularly if it directly challenges their role in that system.
A New Type of Doctor for a New Type of Healthcare System
Future Doctors will need to be more flexible and willing to integrate into a rapidly changing Healthcare System. The old criteria may no longer be enough or even considered for future candidates applying to medical school. If we are really moving toward a new platform for delivering healthcare as I have proposed in this blog than the criteria for selection may need a disruptive innovation of its own. Pre-Med students may need to prove their "competitiveness" by demonstrating their ability to integrate as a team member in a complex-adaptive system. Either way future Doctors will, most likely, not be playing by the rules of the current system but a system that is still in its evolution. My advice to all medical school admission committees. As always, choose wisely and look to the future, because who you choose will be building the next legacy system.
Saturday, March 11, 2006
Since I am a relative new-comer to the world of blogs, playing catch-up is a constant exercise. Lately I've been reading more and more on the concept of bandwidth and the need for multiple tiers of service. My healthcare-system-centric view of the world forces me to consider how this may be affecting the concept I've focused on in this blog. Which is: What we are experiencing as a Healthcare Crisis is really the transformation of our Healthcare System from an older, more established paradigm to an emerging, new paradigm for delivering healthcare. So what got me interested in bandwidth?
There is a very good chance that the only reason you are reading this blog is because you stumbled across it on your way to something else. Be honest, you know it's true. I tend to find a lot of interesting things that way on the internet. I ran across a blog Mark Cuban wrote on the subject of bandwidth and immediately started wondering how this could affect the future of Healthcare. His discussion focused on "multiple tiers of service" and the development of "HOV lanes" or "toll roads" within the bandwidth to access these services. The idea is that there needs to be "mission critical reliability" for "mission critical applications". In a recent blog of his I commented that this may mean the bandwidth equivalent of "911 lanes" for "medical service lines". I'll leave the discussion and debate of creating tiers for bandwidth traffic to the more informed minds, but I couldn't help but wonder what role this may play in an emerging, new paradigm for delivering healthcare.
Out With The Old And In With The New
There is a steady drumbeat of support in this country for the idea that our Healthcare System is in ruins and is crumbling before our eyes. I have a different opinion. What is crumbling before our eyes is the old paradigm. At its foundation is the patient-physician relationship. Physicians have been the gatekeepers to the information and services this great system can provide. What if the nature of that traditional, established role was being challenged? I believe that is what is happening and it makes for some unsettling times. Some might call it a crisis. Changing a model for delivering healthcare is not going to be an easy or very comfortable experience for those of us in the trenches. Access to healthcare information and services are already beginning to become available through alternative venues. I think this is just the beginning of the challenge to the old paradigm.
It's Only the Beginning
Nurse Practitioners and Physician Assistants are beginning to independently provide basic Primary Care health services through outlets such as MinuteClinic, and Medspot. More are sure to come. To further improve access to healthcare services patients can now get advice over the phone via Dial-a-Doc or place an order over the internet for their pharmaceutical needs via Kwik-Med. This is to say nothing about the vast archives of information on medical research available on the world wide web. Despite growth in the cost of healthcare I think these are subtle but very real trends for the future of healthcare. All seek to improve access, decrease costs and provide services for, what Clayton Christensen refers to as, "overshot customers" using "disruptive innovation".
The Anywhere-Anytime Healthcare System
The convergence of easy access to: low cost providers, service selection and real-time availability to health information technology points to the internet. It is becoming apparent that not all healthcare needs require an appointment in a Physician's office or even a Physician. I've discussed this in a previous blog. What if we could not only access a "Provider" anywhere-anytime but also have that visit immediately recorded in our healthcare record? I'm not talking about a real walk-in clinic, but a virtual walk-in clinic. It would be open 24/7 and available wherever and whenever you can access the internet. Medical service lines would be offered much like cable TV channels or pay-for-view programming. If you have a relatively minor, but urgent healthcare need you can access a virtual provider via the internet. The Healthcare Tier you subscribe to will determine the level of interactivity you will have with your virtual reality provider. Customized packages can also be included to further enhance the experience. All information on the virtual visit would be stored in a personal health information record via the National Health Information Network.
Do We Need Emergency Lanes for the National Health Information Network?
With the anticipated growth of bandwidth use, the question remains: Will there be a need for "911" or emergency lanes within the bandwidth for those with pressing healthcare needs and is this going to be a "mission critical application"? My guess is that if it reduces the number of those with non-urgent/non-emergent needs in the Emergency Department and Physician's office waiting rooms then it will be worth the investment. The key is to not only provide access to the service but deliver it at a markedly reduced cost. The other potential bonus is that with improved access and low cost people will seek advice earlier in the course of a disease and, with any hope, avoid the catastrophic effects of late intervention. Virtual Providers could not only treat minor health problems but also get patients into see Physicians earlier in the course of a disease where they can be maximally effective. Now that is what I call mission critical.
Sunday, March 05, 2006
Why is it important to understand that the changes we are experiencing in Healthcare are appropriately described as a crisis? First we must understand what a crisis is. When we use that term to describe an experience most people think of the the experience expressed as a traumatic event. It conjures up images of fear and confusion. While this can accompany any crisis the primary meaning of the term is "a critical or decisive moment". If we are experiencing a Healthcare Crisis we must see beyond the fear and confusion and act decisively during that critical moment. I would argue that it is not just one critical moment or decision but a series of them which we must engage. This will take some planning.
Kind Of Like Being a Teenager But Not.
The position I have taken on this blog is that what we are experiencing as a Healthcare Crisis is a transformation process. We are undergoing a paradigm shift in healthcare delivery. In this process we are transforming from an older, established model for delivering healthcare into an emerging, new model for delivering healthcare. In a previous post I compared it to another period of potential "crisis" in human development. That is the transition from childhood to adulthood that we call puberty and adolescence. The whole period of time can be seen as a "crisis" for the individual experiencing the transition but is in fact a series of developmental steps that are essential for human growth and maturity. What distinguishes this type of development from that seen in Healthcare is that the stages of development are anticipated and predictable. As an individual develops they can encounter problems, and while those problems may be unique to that individual, they are not necessarily considered unique to those who have already matured into adults. For the most part this developmental step is charted territory and there are plenty of experienced travelers available to guide the way. This is not necessarily so in the development of a complex adaptive system such as Healthcare.
Who Will Show The Way?
What we are missing in this current Healthcare Crisis is a map. A plan for getting us from where we are, to where we wish to be. While we lack such a map we do not lack those who think they know the way. The reactions to the crisis fall into two camps both of whom claim to have the solution. There are those who see the crisis as one problem which requires only one solution, and those that see it as many problems requiring multiple solutions. The extremes of these two are the "Single Payer, We Need a Socialized Healthcare System" camp and the "Free Market Capitalists, Let the Market Solve It" camp. They each claim to own a map that will guide us along a path that neither of them has traveled, to a place neither of them has seen. That approach may work well in a simple system moving from point A to point B, but is not particularly suited for a complex adaptive system. Kevin Dooley says in a complex adaptive system the order is "emergent as opposed to predetermined". In addition a complex adaptive system's "history is irreversible" and its "future is often unpredictable". Deciding which way to go will not be as simple or predictable as we would like to believe it is.
Where's Christopher Columbus When You Need Him?
If this is uncharted territory there is no map. So how do people travel in uncharted territory? Well there was a time when it was not uncommon to travel without a map. People didn't always arrive at the destination they anticipated but could discover something greater along the journey. Columbus sailing to the Indies and discovering the new world comes to mind. He created the map along the way using dead reckoning as his navigation tool of choice. If we have no idea what this emerging, new model for delivering healthcare is going to look like what makes us so confident we know the path that will lead us to it? I think we need a form of dead reckoning to make our way through this territory. The goal is to create a map that will lead us to a model for delivering healthcare that is far superior to the one we currently have. If this is truly a paradigm shift then that model and the path to it will look much different from the ones we have. The question is how do we create a map of this uncharted territory?
Map Making 101 for Complex Adaptive Systems
Such a map will need to employ certain features in its creation. It will need to be built bit by bit with each new change submitting to a form of natural selection. In a complex adaptive system the basic building blocks are agents which "seek to maximize some measure of goodness or fitness by evolving over time". The plan can be expected to undergo three types of change according to Kevin Dooley. "First order change, where action is taken in order to adapt the observation to the existing schema; second order change, where there is purposeful change in the schema in order to better fit observations; and third order change, where a schema survives or dies because of Darwinian survival or death of its corresponding complex adaptive system." Our attempts to fit the observations of the Healthcare Crisis into existing constructs such as "Socialized Medicine" and "Free Market Economics" may be first order changes and inadequate to deliver a sustainable long-term solution. Some other type of construct or schema may be necessary for a second order change to better fit the observations of the crisis at hand.
The Best Map Is The One That Works
From the outset we must acknowledge that it is a journey through uncharted territory. We must recognize that the journey may take longer than anticipated but will ultimately have a beginning, a middle, and an end. There are a lot of educated guesses about which direction we should take and what we will encounter along the way but nobody knows for sure. We must be very clear on what our objectives are along the way and employ a feedback system to guide course corrections as needed. Each phase of the journey will have its own set of problems that must be resolved before the journey can proceed any further. These problems must be prioritized as to their immediate importance to the journey. Some of these problems will be predictable and can be prepared for in advance. Others will need to be resolved as they are encountered. We must think of this journey as an essential step in our development as humans. We must never forget the final goal is to improve the health of ourselves, our society and our planet. We must be willing to seize the moment and make the crucial decisions before us. If that means we must improve our understanding of complex adaptive systems than that is where we begin the journey. As Francis Bacon once said, "Nature to be commanded, must be obeyed."
Thursday, March 02, 2006
The most important and enduring lessons learned along the way in life are usually the most personal. In my recent journeys I discovered this simple truth once again. I write in a journal almost every day and have done so for years. Toward the end of last year I noticed a disturbing trend in my daily observations. They tended to revolve around the issue of the healthcare crisis in the United States and my increasingly negative opinions of it. There was no shortage of disparaging remarks and they covered the gamut. The list included: medical liability, health insurance companies and their CEO's, trial lawyers, hospitals, government officials and of course my fellow colleagues. I had enough and I quit. I closed my practice and went on a sabbatical. It was one I believed would be a permanent one from the healthcare industry. One day something happened and that all changed.
I Would Ask Different Questions
It was a typical day. I woke up, made some coffee and sat down to write in my journal. It was now just over three months since I last worked in healthcare. I was about to begin another journal entry in what would have been another rant on the despicable state of our Healthcare System. As I picked up the pen a question crossed my mind. What if I'm wrong? What if all my negative musings were the result of how I framed questions and not an accurate reflection of what was really happening in healthcare. There is an amazing property of the mind. When asked a question, it seeks an answer. (News reporters learn this early in their career and use it to their advantage when investigating a story.) Often-times the answer the mind seeks comes back in a form that mirrors the emotional and intellectual state from which it was generated. If you ask what is wrong with this god-for-saken Healthcare System the mind will seek problems that support that view of the system. As it turned out it was not a typical day. I started asking different questions and started getting different answers. It wasn't until I completely separated from the actual practice of medicine that I could begin to view it from a completely different perspective and ask different questions.
Seek Different Answers
That one simple question made all the difference. It led to a different way to not only view healthcare but also became a tool to ask questions that led to a deeper understanding of the Healthcare System. What if what we experience as a healthcare crisis is really a transition point in the growth or evolution of healthcare? That would mean we are transforming from a system we have known all our lives into one with which we have no previous experience. The process seems frightening and conjures up images of a crisis on a daily, if not constant, basis. For some it may seem like puberty and adolescence revisited. That period of time when we undergo the physical, psychological and social changes that takes us from childhood to adulthood. No one would doubt the importance of such an important period of time in human development or the necessity of the changes that must occur, but just try to point that out to an adolescent. Their daily lives are filled with more important concerns like: acne, dating, popularity, peer pressure, good grades, getting a driver's license and appearing independent, especially from their parents. They really don't have the time, inclination and in some cases the emotional and intellectual capacity to "get the big picture". It isn't until we emerge out of adolescence that we can take in that view. Even then we move on to the next phase of development and leave behind such valuable insights.
And Live a Fuller Life
So back to my original question, "What if I got it wrong?" What if the healthcare crisis is a transformative process? What if all of the problems we accumulatively interpret as a crisis are really the necessary and oftentimes painful steps required for our Healthcare System to transform from what it is to what it can become. It doesn't mean that the problems we experience on a daily basis are not real problems. They are. It is understanding their role in that process. Healthcare has undergone many transitions. There once was a time when we had no antibiotics to fight infection, chemotherapy to fight cancer and surgery to treat operable pathologies. Sewage disposal, water treatment and public health policy were non-existent for most of human history and yet we eventually began to incorporate these great advancements into our system. I think the time has come again. It is a necessary and yes even painful process at times, but it will ultimately strengthen our Healthcare System and our society as well as prepare us as a people for the next phase in life.