Health Care IT — An Evolution or Revolution?
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Welcome to the Party, Pal
When Microsoft founder Bill Gates speaks, people listen. As a result, I’ve had many people send me the op-ed he recently published in the Wall Street Journal on the state of health care.
His commentary basically said three things.
First, advances in medicine are amazing, and the system can do more today than at any time in human history. Second, it’s still operating at something less than an ideal state, because we haven’t digitized critical clinical information that could be distributed throughout the system to support caregivers and patients at the point of care. And third, he said it’s time for an internet revolution in health care — one that uses technology to break down information fragmentation — because technology can be a powerful catalyst for change.
He’s absolutely right about points one and two.
The system today does do marvelous things — which also has something to do with the rise in costs, by the way. More stuff usually means more spending on more people. And his concerns about information fragmentation are right on. But I wonder about the third point he makes. Can the technology itself be the catalyst he supposes it can be?
Bill Gates, meet Dr. Bruce Landes. Dr. Landes is the President of Southwest Physicians Associates, a Dallas-based independent physicians association with 1,300 physicians. Here’s what he had to say about digitized clinical information technology in a recent issue of HealthLeaders Magazine. “You have to realize that physicians have been trained four years in med school, then three to seven years in post-graduate training. The funny thing is that they want to take care of patients. They don’t want to become specialists in creating medical records. They look at the medical record as an incidental cost of doing business. Many EMR programs act as if the medical record is the whole point of the patient encounter. It is just not.”
And therein lies the rub. Many clinicians aren’t buying what the IT folks are selling when it comes to the benefits and opportunities associated with EMRs, the internet, and digitized, transportable clinical information. The HealthLeaders article states, “Their (IT proponents’) contention that EMR will enhance patient safety, improve clinical outcomes and trim unnecessary expenses has fallen largely on deaf physician ears.”
Along these lines, I heard an interesting comment during a presentation on Great Britain’s efforts to remake its clinical information system recently. And remember, in Great Britain, the government IS the system - so they should have a lot of leverage to make things happen. The speaker said that this apparent leverage was not really leverage at all. He said that until people figure out how to make it worth it for practitioners to practice as teams and not as individuals, and to see the value of integrated clinical information systems, no amount of top down control or systems development on its own was going to make that much of a difference.
And he didn’t mean money when he said “worth it.” What he meant was finding a way to convince clinicians that it would be worth it to practice across specialties and within a framework of proven approaches to deliver and manage health care services for complex patients, using a common clinical information system. He went on to say that this is not the way medicine is practiced — in his country or most others.
When I hear comments like these, I don’t come away thinking we have a technology problem. It sounds more like an organizational issue that looks like an IT issue. I know that some people think if we just connect the clinical information dots with IT solutions, the organizational issues will go away. But I’m not convinced that more online capabilities and digitized clinical information solves these problems. In the end, IT is just a tool. It’s how it gets used — and the motives, interests and expertise of the users — that makes it a great tool or a non-issue.
If Bill Gates is serious about this space, he’ll spend some time thinking about how we educate physicians, organize care delivery and study performance before he worries about IT. What he’ll discover is that we train clinicians to be autonomous performers — wedded to their patients and their departments first — and all else after that, that our care delivery system isn’t organized to treat chronic, complex cases, and that we spend almost nothing as a nation on trying to understand how we implement the knowledge we already have about what works and what doesn’t on a day to day basis. (See my previous post on this topic.)
If he comes up with some ways to change these fundamentals first, it would then make sense to consider how an IT strategy can complement these insights. But hey — he’s a wicked smart guy — way smarter than me — and if he wants in to the health care space — to quote NYC Detective John McClain — one of my cinematic heroes — “Welcome to the Party Pal!” Happy to have you along.
Very well said.
Excellent post.
Charlie,
Let me first say that IT is not the ’solution’ for anything, regardless of what the salesman says to you. Information Technology is simply a tool that enables a solution. Hint: That solution must be designed BEFORE you slap an IT tool on top of a problem. Otherwise - bigger problem! But you need to know what the problem is before you can solve it. You say it’s organizational. I say you are on the right track, but it’s bigger than that. Waaay bigger. Organizational implies roles & responsibilities. But, we need to define - at the very least - the organization’s purpose before we can assign any roles. Let me illustrate. Dr. Landes said: “the EMR is not the point of the patient encounter.” I agree. However, here is logical question #1 (BTW, I love questions): “So, what exactly is the point of the patient encounter?” And (once we have answer #1), here is logical question #2: “OK, what do we need to do to ensure that the encounter fulfills it’s intended purpose (the point)?” And (once we have answer #2), here is logical question #3: “How do we measure the success of that encounter?” The reason we are having such difficulties is because there is NO consensus among the protagonists of Health Care on the answers to those 3 fundamental questions. Go ahead, ask around. Ask the primary care Drs, ask the health insurance folks (you know them), ask the patients, ask the hospital administrators, ask the lab technician, ask the nurses, ask the politicians, ask the software manufacturers, ask the investors, ask the drug companies, etc. Not until those questions are answered FIRST and we have consensus at the our health care leadership level can we begin to develop the processes that will form a viable health care infrastructure (read: The solution) and then develop an organization to support that model and (lastly) slap an IT tool to enable the whole thing to work (faster).
Pretty monumental you say? Yes. That is exactly why it is such a monumental problem, or should I say… “wicked”?
To the extent to which Bill Gates wants to help “put people at the center of the health-care system, and put them in control of all their health care information,” bravo Bill Gates.
Also, if I may be forgiven for mentioning it, about this 1300 member doctors group in Dallas–aren’t such groups as these, with their increase in market power, responsible for an important share of the rise in health costs recently? So I don’t really see their advocates as disinterested.
I agree completely; until doctors recognize that 21st century medicine must be a team sport, shared medical records won’t create the collaboration we need.
On other hand, EMR can reveal who isn’t playing with the team. When I wrote my book, one solo practioner who I interviewed said “I don’t want someone looking over my shoulder.”
With electronic medical records, someone is looking over your shoulder, seeing what you’re doing and what you’re not doing. (Even if the EMR is shared by doctors in separate practices who are only linked electronically).
And if you’re ignoring what other doctors are doing (in terms of prescribing, etc.) someone is likely to call you on it–in a collegial way. (Or at least that’s what one would hope.)
That does happen at places like the VA and Kaiser.
By contrast, no one knows what the many solo or small group specialists in Manhattan are doing. Are they practicing good medicine? Some are; some aren’t.
Finally, I think the large multi-speciality group practice will ultimately become the norm in many places simply because, given the cost of real estate, not to mention IT, it’s getting harder and harder for a small group practice to stay afloat.
Agree with you. And don’t forget the nurses, nurse practitioners, physician assistants, medical records staff and others. I know of one very large practice where the physicians (and no one else) were “consulted” on EHR implementation. The roll out was a total and complete (and expensive) failure because the organization did not consult with the heaviest users of the EHR (and the paper records).
Also, in the health care space, we are all “learners” and should be. As you know, health plans don’t approach their daily mission and business challenges standing in the shoes of a nurse or a hospital CEO or a consumer. We should all trade places occasionally and the industry would be better off. We need constant education to understand and respect the perspectives of all stakeholders in the health care arena.
I think there is plenty of room in this space for you — and Bill Gates. : ) I just hope he truly steps into the arena, as you have. Your thoughtfulness and insight constantly raise the bar.
I enjoyed your post very much. EMR is an important topic right now and the more businesspeople like Bill Gates start to see the potential of EMRs, the faster the profession is going to have to work to keep up. In regards to your comment that physicians, being autonomous performers, are inherently resistant, I wonder if it would be best to begin the transition to EMR by reaching physicians before they realize their autonomy- during their training. We’ve already proven time and again that our country doesn’t do well with incremental change (see health care reform, decimal system…) and clearly the transition will be not only beneficial but necessary for congruence between physicians, health insurance companies, and other providers. Teaching hospitals are a great place to introduce the technology both to practicing physicans and to students who can then use their knowledge some day in their own practices.
Nice post! I’m a huge Bill Gates fan.
Wearing my system architect hat, my mantra has always been “what is the problem you are trying to solve?” Switching to the clinical analyst hat, I would argue that an EHR, by itself, solves nothing. What does solve problems is to think about the information a clinician needs to see, or record, during typical encounters.
From the software specification side, this is a use case. Use cases, however, go only so far; they don’t reflect the added value that could come from EHR information in a broader context.
Over the last year or two, I’ve been experimenting with how best to present information, and make it easy to focus the encounter, to be sure the appropriate actions are taken, and there’s a decent way to see patterns in data. Much of the recent work has been presenting physicians, in office practice, with a complex medical record in a structured way.
For example, the first page lists reasons for the encounter, with goals. While I haven’t seen it used to any great extent, and I fully understand that a reasonable number of people have impaired color vision, I find it well-received, for patients with multisystem disease, to color-code by system (e.g., red for cardiology, green for endocrinology). The color code is consistent through:
*Goals for encounter
*Current medications and therapies
*Laboratory or patient-measured values (I find having trending, or some statistical analysis, very useful here)
*A checklist of probable actions, such as prescription renewals, consulting referrals, etc. When these will go to different people, such as a nurse for pharmacy contact and a clerk for referrals, these usefully are on different pieces of paper, so they can be passed out.
*Significant previous medical history and labs, as a backup.
Now, all of those things involved data with the EHR, but I’m not showing clinicians the EHR, but what it can do for them.
In the managed care environment, anything that can cut administration is welcomed. There are some very simple additions to prescribing software that no one seems to use. Already in the EHR is the patient’s benefits manager. Most benefits managers have formularies, yet I have never seen a e-prescribing system that checks if the drug order is in the formulary. Being warned that a drug won’t be approved is most efficient at prescribing time, so a substitute can be suggested, or, if there’s a need for justification, the process can start immediately, rather than waiting for refusals and back-and-forth with the patient, pharmacy, PBM, and clinician.
How can we best present “this is what the EHR can do for you” rather than “we will create an EHR?”
Your summary regarding regarding the Bill Gtaes Wall Street Journal article…”If Bill Gates is serious about this space, he’ll spend some time thinking about how we educate physicians, organize care delivery and study performance before he worries about IT” is compelling.
As a HIPAA consultant, I find clients confused, upset and frustrated by HIPAA regulations. In case after case, I have found the greatest part of my consulting is an educational effort…the results of which leave a healthcare client understanding HIPAA regulations, aware of how those regulations can benefit the organization and appreciative of a framework for conducting their security practices. In short, following precisely your prescription…thinking about how we educate physicians, organize care delivery and study performance.
Read more at HIPAA Vital Signs http://www.dgpeterson.com
Grant Peterson, J.D.
HIPAA Consultant