Health Care System 2.0

The Time Is Now

Everyone agrees that our health care system is in need of serious reform. Some go so far as to say we need to transform our health care system. I have some different ideas on this subject. I don't think we need to look to the future for the transformation of our health care system. I think it is happening right now. This is it. This is what it looks like and feels like. We seem to think it is going to be some type of pleasant experience. It's not. It is this way because we must simultaneously dismantle the model upon which the established paradigm of delivering health care is built and replace it with a new model upon which the emerging paradigm of delivering health care will become established. It must do this and continue to deliver health care to our society. It is not an easy task to do but I believe this process has already begun.

The Gatekeeper

The established paradigm of delivering health care is based on the classic patient-physician relationship. Let's call this paradigm Health Care System 1.0 to borrow a software version analogy. What we have witnessed over the last forty years has been an unprecedented attack on this relationship. Much of it has focused on the role of the physician as the primary gatekeeper to the health care system's vast resources. Most if not all major consultations, prescription medications, in-patient and out-patient treatments and operations were accessed by first going through a physician. If you need anything available in Health Care System 1.0 you must first be granted access by a doctor. In version 1.0 this made sense. The doctors education and training was an essential element needed to direct the patient toward the best available resource. It was the doctors experience with version 1.0 that helped guide the patient through this complex-adaptive system. So where is the evidence that this relationship is under attack or even strained?

Under Pressure

The patient-physician relationship is experiencing multiple sources of pressure. Reimbursements for physician services continue to be cut or at least not increase in a manner to keep up with the cost of living. The rise in medical liability rates has also created a pressure by increasing practice expenses. This means that each patient contact results in reduced net payment to the physician and an increased exposure to medical liability risk. In order to maintain the same level of income a physician must gravitate toward contacts with either reduced risk or improved reimbursement per contact. In addition, insurance companies want a greater say in what treatments a patient may undergo or what medications they may be prescribed. This increases the "hassle factor" for physicians struggling to match allowable treatments and medications with what they believe to be the standard of care. What is slowly happening is the role of the physician as gatekeeper is being stripped away. The combined effect of decreased reimbursement, increased expense, increased medical liability risk and outside sources directing medical care is passively conspiring to remove physicians from this role. Hear me out, I said remove physicians from this role, not entirely remove physicians from the Health Care System. So who or what will assume this role?

Design Specifications for Gatekeeper 2.0

Clayton Christensen touched on this in his recent book, Seeing What's Next. I referenced this source in a previous blog addressing disruptive innovation and trauma centers but it's worth repeating because it really focuses on how this process is currently progressing. He summarized this in the chapter titled "Healing the 800-Pound Gorilla".

1) Scientific progress leads to better categorization and the development of rules guiding prevention and treatment.
2) Those rules open the door for less-skilled people to do what previously required deep expertise.
3) Non market forces affect the market for innovation by influencing industry players motivation and ability.

I believe as we get better at defining the rules and integrate them into our growing network of information technology these will become the protocols and pathways used by the less-skilled people. This is already in place for mid-levels practicing with Minute Clinic. The protocols and pathways will need to be stored in a platform that can access the information at all times. The artificial intelligence built into this platform will guide the mid-level and eventually even less-skilled people through the maze once only entrusted to a physician. It will need to do this in a way that improves health care access to the patient, at a lower cost with "as good as" results. Minute Clinic and its copycats are already doing this for relatively minor health problems. As they get better at this process they will inevitably migrate up the value chain.

Summer Is Coming

So am I for it or against it? I am neither. I see it as inevitable. It would be like asking me if I am for or against the coming summer. Since I live in Phoenix, Arizona it would be like asking me if I endorse one hundred and fifteen degrees in the shade? I don't really endorse it one way or another I just prepare for it if I plan on being here in the summer months. Between now and then the average daily temperature will slowly rise. It doesn't happen all at once but a little bit at a time. I see the coming of Health Care System 2.0 the same way. I guess in some ways I endorse it because I hope it really will deliver on the promise of an improved Health Care System. Either way, just like the coming summer, I plan on preparing for it by adapting to the daily changes.

Trauma System 2.0

Health Care System 2.0

There is an evolving change happening in trauma systems that is occurring within the context of our "Health Care Crisis". Before I discuss this any further I need to remind you of the original concept of this blog which describes, what I believe is, this greater context. I've discussed this previously but let me summarize this idea. What we are experiencing as a "Health Care Crisis" is really the emergence of a new paradigm for delivering health care. The established model of delivering health care was built on the idea of the Patient-Physician relationship. Physicians acted as gatekeepers to the services, accumulated knowledge and experience of the health care system. The nature of this relationship is changing. It is evolving into a Patient-Provider relationship where the "Provider" will be an information technology based platform that uses artificial intelligence for delivering health care. What we are experiencing now as a "crisis" is the deconstruction of the established paradigm, the conserving of the essential elements of that paradigm and the building of a new model on the foundation of the older model. If you are wondering where the deconstruction is occurring look no further than where everyone is pointing to as the cause of the crisis.

The Prime Directive

Not a day goes by when someone in the popular media is not commenting on the health care crisis. We hear it all the time. "The system is collapsing." "Medical costs are spiraling out of control." "There are over 45 million Americans without health insurance." "Greedy trial lawyers are suffocating the health care system." "Insurance and pharmaceutical company executives are profiting off of the sick and dying." The list goes on and yet amazingly despite these complaints medicine on the whole continues to improve. How does that occur? The reason is because the system was designed to improve the health of our society over time. That is the prime directive. It says nothing about how we will deliver that directive. It is only concerned with improvement over time. If that means disrupting a time honored delivery platform to replace it with one that is fundamentally better than so be it. This will and is affecting all sub-systems of Health Care version 1.0.

Trauma System 1.0

The latter half of the 20th century saw the dramatic development of trauma systems and the improved delivery of health care to the acutely injured patients. It took the bold actions of Trauma Surgeons such as R Adams Cowley, MD to advocate for those systems. He and others of his generation identified the need for Trauma Centers and impressed upon the leaders of the time to implement such systems. While slow to develop these systems have proven their worth to our society. These systems were primarily established through the hard work of those who worked in the trenches, so to speak. They are the surgeons, emergency medicine physicians, nurses, paramedics, emergency medicine technicians and all other clinical personnel who evaluated and treated the people injured by traumatic mechanism. In time these professionals created societies and networks for the physicians, nurses and allied health personnel. This allowed for greater improvements in the delivery of trauma health care. There are limits to this process and I believe we are approaching them.

The Trauma Club

The people who work in trauma tend to be a tight-nit group. It is a very small club and there is a belief that if you have never done time in the trauma trenches then your opinion doesn't matter. We're the insiders and all others are the outsiders. While this sense of camaraderie and control was essential for the establishment of trauma systems I believe it may be the very factor that is holding back their further development. Trauma Surgeons are the main gatekeepers to the definitive treatment centers for trauma care. As we continue to improve we have become victims of our own success. It is an ironic twist of fate that as a Trauma Surgeon gets better at what they do, they tend to do less of what they were originally trained to do, which is surgery. The majority of the trauma patients in the National Trauma Data Bank (NTDB) have minor injuries as measured by the Injury Severity Score (ISS). It is becoming increasingly obvious that not all of those patients need to be evaluated by a Trauma Surgeon. The ones who benefit the most from the services of a Trauma Surgeon are those with more severe injuries. In order to direct those patients to where a Trauma Surgeon is requires a highly developed Trauma System. Taking the current systems to the next level to meet those needs is going to require Trauma Surgeons to give up something they worked so hard to get. That is, control of those systems.

"A man must not deny his manifest abilities, for that is to evade his obligations."
Robert Louis Stevenson

We have gotten so good at what we do we have forgotten what it is that we don't do so well. Trauma Surgeons are leaders in the trauma room and operating room. We make difficult decisions often based on little information which can directly affect the life of our patients. We perform regularly and successfully under stressful conditions. It's a small world we live in. We're distrustful of outsiders and certainly don't wish to allow others to control our destiny as society so often grants us the privilege to do for it on a daily basis. What we don't do so well is run large scale operations of the system type. There are others, particularly in the world of business, who are much better at doing that. They understand and work on a daily basis with the concepts of "complex systems architecture", "disruptive and sustaining innovation", "economy of scale" and "value chain". Ideas such as these are essential for understanding the way organizations progress and succeed. Trauma systems are at the threshold of a new type of delivery system. They need strong leadership of a different kind. The kind of leadership needed is one which has experience at running large complex systems. Trauma Surgeons will need to make some decisions. They can go back to doing what they were trained to do. They can recruit others from outside the club to run these systems. Or they can venture outside the club walls and seek the education and training it takes to manage these systems. One way or another Trauma System 2.0 is coming. It will be built on the conserved essential elements of Trauma System 1.0. While version 2.0 may diminish the role of the traditional Trauma Surgeon, let us not forget that the leaders of it will be standing on the shoulders of those giants who built version 1.0.