Monday, January 30, 2006

Transform, Not Just Reform, Healthcare

Designing a Different and Better System

It seems like everywhere you look today someone is calling for Healthcare reform. Let's think about this for a second. What is the difference between reform and transform? Here is a sampling of what you will find in the Merriam-Webster dictionary.

Reform: (vb) 1) to make better or improve by removal of faults 2) to correct or improve one's own character or habits (3) (n) improvement or correction of what is corrupt or defective.

Transform: (vb) 1) to change in structure, appearance or character (2) to change in potential or type.

The problem with describing the needed changes in Healthcare as "reforms" is that it limits those changes to perceived defects or faults. I would rather see what is happening in Healthcare as a much bolder vision unfolding before us. Over the last two weeks on this blog I have been toying with this idea. I've finally gotten around to drawing up an outline as I see it. I realize I will be making many changes to it in the future, but for now it is a first draft. It is somewhat lengthy for a blog so I apologize in advance. It is also very Doctor-centric but I figured, what the hell, I have to start somewhere. Constructive commentary is appreciated. I will leave you with one simple question. Is an open source or open design model for creating a new Healthcare System possible?

Hypothesis: The healthcare crisis in the United States is due to the conflict that arises when an emerging paradigm for delivering healthcare services challenges the established paradigm for delivering healthcare services. The crisis will resolve when the new emerging paradigm becomes established.


1) The transformation will occur over three main phases, which can be best characterized as a paradigm shift that follows an S-curve pattern. Each S-curve represents the life cycle of a paradigm. A paradigm shift occurs when the upper part of the S-curve, representing the established paradigm, merges with the lower part of the new S-curve, representing the new, emerging paradigm.
a) Phase 1: This is the point of greatest overlap between the two paradigms and therefore the period of greatest conflict. It begins at the upper inflection point of the S-curve of the established paradigm and ends just before the lower inflection point of the S-curve of the new paradigm.
i) The established paradigm is reaching the point of diminishing returns. It requires greater amounts of resources to maintain and develop any further.
ii) The new paradigm is just beginning to emerge, however due to its relative immaturity it is characterized by a lack of organization, high costs and failed start-ups.
b) Phase 2: This is seen as the point of transition between the established paradigm and the new emerging paradigm. The established paradigm loses its standing as the pre-eminent source of healthcare services and the new paradigm begins to assume that position. It occurs during the lower inflection point of the S-curve.
i) The established paradigm becomes impractical as it is seen as inefficient and too costly.
ii) The new paradigm for healthcare delivery begins to become more easily accessible, efficacious, and cost efficient.
c) Phase 3: This is the period of accelerating returns of the new paradigm. It is seen as the upward slope of the S-curve between the lower inflection point and the upper inflection point.
i) The formerly established paradigm passes into history as the shoulders upon which the new paradigm stands.
ii) The new paradigm takes its turn at becoming the established paradigm until a new challenger arrives, and Phase 1 is started over again.

2) If this is a true paradigm shift then it must pass a simple Kuhn Test by answering in the affirmative to the following two questions.
a) Does the new paradigm appear different from the established paradigm?
b) Is the new paradigm better than the established paradigm?

3) The new emerging paradigm will conserve the fundamental reason for the existence of a Healthcare System which is to deliver and optimize the health of those within the System.

4) The cornerstone of the established paradigm for delivering healthcare is the patient-physician relationship. It is built on trust and assumes a value-for-value exchange.
a) Without the patient-physician relationship as defined by the current standards, the established paradigm would collapse.

5) The cornerstone of the emerging paradigm will be the patient-provider relationship.
a) The term "Provider" will become redefined as progress is made through the different phases.
b) This new relationship will prove to be more convenient, efficacious, and affordable.

6) Enabling technologies will be essential for the transformation to occur.
a) These will be technologies that currently exist but will be restructured in a unique way to facilitate the paradigm shift.

7) Enabling legislation will be essential for the transformation to occur.
a) Legislation that facilitates the transition from the established paradigm to the new paradigm will be necessary as each phase develops.

8) The variability of practice patterns will be minimized as each phase passes and the delivery of best practice patterns will become the status quo.

9) The delivery platform of healthcare services, where the physician acts as the gatekeeper, will become transformed into a platform that can consistently and continuously deliver the full capabilities of the system.

10) Health will be redefined from being not just an absence of disease to being fully alive and engaged in the living of life.

Transformation Projections

1) Phase 1:
a) Physician shortages will become more prevalent due to increased demand, particularly in "underserved" areas. Physician portability and commitment will be hampered by: Length of time it takes for credentialing and licensing, High cost of establishing a practice while paying off student loans, High cost of malpractice insurance, Limited practice options, Delayed payment of services provided, Excessive workload and duty hours.
b) Physician specialization will increase in an attempt to manage the increasing medical knowledge base.
c) Specialization increases specialty autonomy and power but decentralizes the power base of physicians as a group and effectively inhibits them from organizing as a whole.
d) The Patient-Physician relationship will become redefined as the Patient-Provider relationship.
e) The term "Provider" will become redefined to include Nurse Practitioners (NP) and Physician Assistants (PA).
f) Providers will begin to use enhanced technologies that utilize basic forms of Artificial Intelligence (AI).
g) The cost of the Patient-Physician relationship will be considered excessive for the services provided for two main reasons.
i) The cost of the physician is high (education, training, practice overhead, malpractice insurance, decreased reimbursement).
ii) The costs of the physician's recommendations are high (Brand names vs. generics, defensive medicine, consumer demand).
h) Costs will rise.
i) As the established paradigm reaches the point of diminishing returns it will cost more to maintain the system.
ii) As the new paradigm emerges it will cost more due to immaturity, lack of organization and failed start-ups.
i) Cost containment measures will come in the form of reimbursement caps, increasing difficulty in obtaining payment for treatment and prescriptions, rising co-pays, etc.
j) Conflict will develop over the "fitness" of Providers to maintain their gatekeeper role for the Healthcare System.
i) The Patient-Provider relationship will become increasingly adversarial.
ii) Providers will be increasingly called to task for their inability to safely and adequately deliver the full service capabilities of the current Healthcare System.
k) Enabling technologies: Computers, PDA's, Internet, Data Storage, evidence Based Medicine, Protocol Development, Basic Electronic Medical Record, Robotic Assistants.

2) Phase 2
a) The term "Provider" will be expanded to include any Interface that is directed by an approved AI medical decision making software package. This will be used independently by the patient for the evaluation and management of low complexity problems.
b) The AI will have current Standards of Care combined with cost effective controls embedded in the algorithms driving the decision making.
i) Physicians of the established paradigm will be instrumental in helping to build the AI directed Interface.
ii) Physicians will define the standards of care.
1) These standards will be embedded in the evaluation and management protocols utilized by the Interface.
2) Confirming the use of the Standard of Care will become the equivalent of "required fields" encountered in most internet database forms.
iii) They will provide the initial feedback to the programmers as to the functionality of the Interface.
iv) Physicians will assume a new role as medical information managers for healthcare teams managing patients.
v) The owners of the proprietary rights to the development and maintenance of the medical decision making software will become liable for the recommendations.
c) Physicians, NP's and PA's will become increasingly dependent on "enhancing technologies" for most medical decision making. They will be primarily responsible for evaluating and managing moderate and complex medical problems.
d) Enabling technologies: Standardized Electronic Medical Record, National Health information Network, Virtual Reality Systems, Performance Enhancing Robotics.

3) Phase 3
a) Most Patient-Provider encounters will be completely managed by an Interface that utilizes approved AI medical decision making software.
i) The Interface will assume the role of the Primary Care Provider and Hospitalist.
ii) An Interface that utilizes advanced robotics will perform most of the low complexity operations.
iii) Human Providers will continue to provide both Interface assisted and non-Interface assisted services where the Interface is unavailable or impractical to use.
iv) When Providers work in a resource deficient or un-enhanced environment they will be held to a different Standard of Care.
v) Enabling Technologies: Advanced Genetics, Robotics, AI and Nanotechnology.

Essential Elements of a New Healthcare System

1) Accessible 24/7/365 from most environments.
2) Maintains the highest degree of up-to-date Standards of Care.
3) It will cost less per service than the current Healthcare System.
4) The Standards of Care and quality outcomes will be transparent and accessible on all healthcare entities.
5) Maintains a universal health care record on all participants.
6) Produces healthcare outcomes that far surpass current best standards.
7) Incorporates other type of Interfaces to facilitate the delivery of healthcare. (Nutritionist, Health Club Trainer, Physical Therapist, etc.)

If you don't think we have a healthcare system, just try to change it.

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