Archive for the ‘Health Care’ Category
Transparency is the new buzzword in medicine. Systems should be transparent with regard to prices, if not costs. Doctors and other providers of healthcare services should publish their costs and fees, too. Various ratings and measurements have been developed in an attempt to measure that nebulous and elusive entity “Quality”. Calls have been made for transparency here as well; hospitals, doctors, and others are browbeaten to release any and all manner of quality measurements so that we might create something one could call an “informed patient”.
The first, and therefore most important challenge in the quest to measure quality is to agree on a definition of just what quality is. Like all rational discussions the first order of business is to agree on terms and the terms of engagement.
Let’s take the question of evaluating the quality of an individual surgeon. What are the salient metrics? Are we concerned with only outcomes? You know, success rates, complication rates, stuff like that. Is there more to the measurement? Should we be concerned with EFFICIENCY, the ability to obtain high quality outcomes in a more timely manner? How about VALUE, the soft and difficult to measure combination of quality and COST? In this day and age of “economic credentialing” in which doctors, hospitals, and other providers are held responsible for the cost of care, not only on an individual basis but also a societal one, it seems as if value is an inescapable aspect of quality, at least in the eyes of our government and the people who actually pay for healthcare.
Quality measures will be different for surgeons of different stripes; we will want to evaluate different complications and their rate of occurrence for an ophthalmologist versus, say, a cardiothoracic surgeon. Even similar adverse events like infection rates will have a different meaning across specialties. One classic example of a surgical complication is post-op infections. From my limited reading about heart and chest surgery it appears that the post-op infection rate is around 1-2%. This would be scandalous in eye surgery where the post-op infection rate is 100X lower, closer to .01-.02%. Stuff like this should be fairly easy to uncover, or at least you’d like to think so. It turns out that even this metric is rather hard to come by since multiple doctors will participate in the treatment of post-op infections, and literally no one offers up these stats uncompelled. Similar issues apply to specialty-specific complications (vitreous loss, graft leak) for similar reasons.
Right away the difficulty of measuring quality is obvious: even the simple quality measures appear to be something other than simple to discover right now.
Outcome measures are even trickier. Since I know eye surgery best let me stay in that arena and use cataract surgery as my example. For our discussion let’s assume that we have magically been granted unfettered access to every eye surgeon’s charts (and that they are all legible, and that they all contain the same basic information). It should be a rather simple proposition to draft meaningful criteria–let’s say “how well do the patients see after cataract surgery.?” Would that it were so. The answer to that very simple question–how well do you see after surgery–depends on several variables, and further varies if you ask the question slightly differently. How much improvement did the patient achieve compared with pre-op? How fast did the improvement come? How well does the patient see without eyeglasses? Is the patient more or less dependent on eyeglasses following surgery? What level of vision constitutes a success? Does the surgeon get the same results with complex cases?
I imagine these issues are not specific to ophthalmology. I can see the same types of questions and complexities in orthopedic surgery, for example. Think about hip replacement–along with cataract surgery and cardiac bypass surgery, hip replacement is arguably one of the most significant medical developments when we think about the quality of life enjoyed by an older person. What defines success in hip replacement? How long do you allow for success to occur for it to be deemed one for the ”win” column? Do we give bonus points for speed in the OR, both from a patient’s standpoint and an economic one? How about a surgeon’s ability to achieve the same level of success in a thin 70 year old tennis player and an obese, cart-riding smoker?
Seriously, if docs can’t come to an agreement about what constitutes “quality”, how can we in good faith measure it? Furthermore, if we WON’T define it we have no one but ourselves to blame when some nameless, faceless 30 year old sociology major in D.C. does it for us.
Nobody asked me (again), but as long as I’m here let me offer up a 3-part proposal to measure and promote quality using surgeons as a theoretical template. Let’s start with a thought exercise borrowed from CrossFit. Fitness training using the CrossFit methodology involves high intensity exercise while trying to maintain near-perfect movement and form. One is shown three targets from a shooting range. The first has random bullet holes all around the bullseye, the second has every shot dead-on perfect, and the third has 95% of the shots within the center bullseye and 5% on-target but not perfect. Which one represents the most desirable CrossFit training strategy?
In CrossFit the answer is “C”, 95% accuracy with the misses still close because this represents the optimal combination of form (accuracy) and intensity (speed). Is this directly applicable to surgery? Well, that depends on how far outside the bullseye the misses land, doesn’t it? And in surgery I think we also need a more accurate measurement of intensity; we need a clock. Speed matters, from both a medical standpoint and a financial one. The shorter a surgery lasts while still hitting the target, the less physically and mentally taxing it is for the patient, and the fewer costly resources (OR time, staff time, doctor time, supplies, etc.) you are consuming during surgery. All things being equal, the surgeon who achieves the desired outcome faster without increasing her complication rate is the better surgeon.
Put surgeons on the clock.
A successful outcome must be explicitly defined for each common surgical procedure. Pre-operative factors that reduce the likelihood of success should certainly be taken into account (e.g. a morbidly obese cart-riding smoker and hip replacement), but care needs to be taken so that a measurement can’t be gamed (two guttata do not constitute a corneal dystrophy and increased likelihood of swelling) in order to work with a lower standard. Surgical societies should show some spine and make a call, define what constitutes a high-quality outcome, regardless of the howling that will emanate from the mediocre and the incompetent. It’s gonna happen anyway, and physicians making the call would be orders of magnitude better than MBA’s and philosophy majors.
Lastly, quality should be measured, publicized and praised, and those surgeons (and other doctors) should be explicitly rewarded with as many cases as they can (or wish to) handle. They should also be paid more. Once we decide what constitutes quality we can measure it and publish the data. People will understand this, just like they understand the data in a box score. Why is it so OK for the baseball player with the highest batting average or lowest ERA to be paid more based on his success, yet somehow the most efficient surgeon who has the best outcomes is labeled a “money grubber” who must somehow be doing something wrong if he is also very busy? We want that high batting average guy at the plate in the 9th inning of a tight ballgame, and we pay him more because of his higher quality outcomes. Why aren’t we doing the same thing with surgeons? The very least we can do is stop accusing surgeons of being successful!
It’s time that we apply basic theories about quality to medicine in general and surgery in particular. Indeed, it should be easier to do it with surgeons. Make a call–define a successful outcome. Pull out a stopwatch. Faster, more efficient surgery is less expensive and generally less taxing physically for patients. Once the data is available be transparent and publish the results. I know what Miguel Cabrera is batting this year; my patients (and potential patients) should know my “batting average” in the OR. While I hold out little hope of being heard on this last point, uncountable articles support the benefit of the carrot at the expense of the stick when it comes to promoting excellence. Higher quality should beget higher pay. At the very least we should stop with the assumption that the busy surgeon is somehow “getting over”, guilty of somehow gaming the system (eg. doing unnecessary surgery) until and unless proven innocent.
She may just be better.
My Dad has been hospitalized for many, many weeks now. My siblings, a couple of the daughters-in-law (including my wife) and I have taken turns either keeping my Mom company or spelling her and just hanging with my Dad alone. We have tried mightily to keep each other abreast of a day’s events, and we have made yeoman’s efforts to help Mom communicate with all sorts of members of the medical community involved in Dad’s care. Man, has THAT been a challenge. The differences in understanding the lingo of medicine, not to mention the vast gulf between the frame of reference that exists between ”civilians” and medical workers on the front line create communication barriers that can seem impenetrable.
Where does the responsibility lie when we enter into a conversation? Let’s define a conversation as the interaction between two people during which there is a purposeful transfer of some kind of information. Let’s refine that by saying that in this day and age we cannot define a conversation as simply as two people talking with one another. We have email, texts, FB chats and PM’s, Twitter @’s and PM’s, phone calls and Skype, and of course plain old face-2-face talking. Any and all of these have been, or yet might be used when we go forward with Dad.
So where does the responsibility lie to ensure effective transfer of information? Upon whom does it rest to make sure that facts or ideas have been successfully transmitted and received? How about the emotional content, the feelings that ride along with the data? Sometimes the emotional content is really the data that’s intended for transfer and is quite obvious, like the color guard accompanying a General. Oft times, though, the feelings attached to the words are as carefully and craftily hidden as a stowaway on a cruise ship. What exactly does it mean when a nurse greets Mom in the morning with the fact that Dad “struggled” the night before?
Here’s my bid: the responsibility lies on BOTH sides of the conversation. Active listening is key. Engaging in the conversation means engaging the individual on the other side. It starts at the very choice of vehicle: to whom am I sending this message? On the receiving end the vehicle should also be evaluated: who sent this to me? Think about it…the universe of topics you would engage with your 75 yo grandparents via text is awfully darned small, and if you are a grandparent who texts you can’t “receive” disrespect in a message filled with contractions and lingo. By the same token, both sender and receiver must be actively conscious of the frame of reference of any “other” in the conversation.
A Facebook status update is like a billboard, meant to be one-way, neither demanding nor expecting a reply. A conversation, on the other hand, is by definition bi-lateral. It requires active listening and anticipatory listening on the part of both people. It requires a shared understanding of the power as well as the limitation of each method one might choose to utilize. The smaller vehicle (text, Tweet) creates the greater distance and so must transfer the more basic information. More nuance or emotional content requires a different vehicle, at once larger (to include the details) and smaller and more intimate (so that everything can be seen as well as heard). Closer.
In the end we are social creatures, driven always to connect. The rules of communication have not really changed despite our ever-increasing ability to communicate, to connect. The more important the interaction the closer we must be to the other. Communication, no matter what vehicle we choose, requires that we listen better. Listen to what is said to us; listen to what we say; listen, especially, to what the other hears.
The responsibility for a successful communication is shared equally by both or all involved. Despite our newfangled world filled with different ways to communicate the most effective strategy hasn’t changed in a few thousand years:
The onus for reducing healthcare costs has been placed squarely in the middle of the backs of physicians. At the same time, physicians are being graded on how well they “satisfy” their patients. Rock, meet Hard Place. Hard Place, Rock.
Two recently published studies referenced pretty much everywhere have shown that individual patients specifically do NOT want to take cost into consideration when it comes to making decisions about their own care. In addition they also do not want their physicians to give any consideration to cost concerns when diagnosing or treating their own illness. Indeed, when given the choice between two treatments of nearly equal efficacy, study subjects overwhelmingly chose the more expensive option for themselves even when the difference in efficacy was very small.
While the authors of the articles citing these studies were shocked at these findings, the only surprise in my mind is that anyone is the least bit surprised by any of this.Think about it. You will personally pay little to none of the difference in cost of the treatment out of your own pocket for a treatment or a test that someone has labeled “better” or “more effective”. You’re telling me you’re not gonna choose that one? Please.
The two great forces aligned against one another in the “Healthcare Reform” debate advocate respectively: market-based incentives in which a patient is given better information in return for shouldering more of the financial decision-making and the importance of the quality of the exerience, and top-down command and control strategies in which both carrots and sticks are applied to doctors in an attempt to get them to provide better care with a more friendly consumer experience while at the same time spending less money. Physicians must provide more and better for less, and must do so under the same zero-sum malpractice game of “GOTCHA” rules we have now.
All of the responsibility for lowered costs with better outcomes and a better quality experience for the patients is shouldered by docs in Obamacare. Accountable Care Organizations (ACO) are lauded for paying physicians a set salary rather than by work done. Unless, that is, you do less work, quality notwithstanding. Getting great outcomes, following best practices, and receiving high satisfaction marks get you a pay cut if you see fewer patients, generate lower test fees, or do less surgery. The Rock.
Play by the rules, see your prescribed load of patients, get great outcomes and practice to the letter of evidence-based medicine, but fail to get those high customer satisfaction marks? Ah…welcome to the Hard Place. Your pay depends on satisfying your patients. Meeting their expectations both for their experience as well as their care. You know, those same patients who only care about the cost of someone else’s healthcare, not theirs. Fail to order the test that rules out the 0.00001% chance of that rare tumor on Anderson Cooper Live last night? BZZZZZT. Bad doctor. 1 out of 10 on the patient satisfaction survey and a trip to the principal’s office to learn about your pay cut.
Man. It wasn’t enough to be in the crosshairs of every plaintiff’s lawyer under the sun (so Doctor, isn’t it possible that you might have saved this patients vision if you’d ordered that MRI to evaluate her headache?). Nope, now we are responsible for balancing the Federal budget while simultaneously giving every patient whatever care they’ve seen on Dr. Oz (“PET Scans–your doctor KNOWS you need one if you have a headache! You could go BLIND!!”). It’s a lot to ask of your doctor.
Unless, of course, it’s someone ELSE’S headache.
We’ve lost the ability to be amazed. As a society, as a people, North Americans not only fail to be dazzled by things that are downright amazing, we have actually become quite blase about, well, pretty much everything. That sense of wonder at the new we celebrate in children is leached out of our kids at ever younger ages. Our ability to be awestruck has atrophied, and any sense of awe, wonder, or amazement that we DO experience is so fleeting that it’s almost as if it was never there.
How did this happen?
This idea, this observation has been stewing in my subconscious for a couple of months now. It popped its cork yesterday after a couple of experiences I had starting last week. The first, interestingly, actually involved seeing people who actually WERE amazed. I flew to and from Providence to visit my folks last weekend. On the way out I sat in the last seat in the plane (doorman to the restroom), on the way back in the very first seat (Walmart greeter). On both legs of my trip I was seated next to 45 year old men taking their very first trips on a plane. Imagine! 45, and never on a plane. These guys were simply awestruck at the notion that they were drinking a Coke inside an aluminum tube that was cruising at 35,000 feet. One of them took about a hundred pictures of the clouds out the window. Those guys were amazed! I let myself get swept up in their experience; it really IS cool, and not even just a little bit amazing, that I could get to my folks 750 miles away in less than 90 minutes!
Experience #2 occurred in my office on a one-day post-op day. Medicine in general, and certainly my field of ophthalmology in particular, is a victim of its overwhelming success. Indeed, this is not too different from the airline industry. We deliver the goods time after time, on time, without a hiccup. So frequently, in fact, that in those rare instances where things are rocky, or there is a complication, we view the outcome as only slightly less horrific than an airplane crash. Even a fantastic outcome, one that would have been so unlikely just a few years ago, is now viewed as some kind of a disappointment if it fails to meet the outlandish expectations of an audience that has been numbed by routine success.
Take, for example, cataract surgery. I had a patient with a very large cataract, a very small pupil, and a flaccid iris–a set-up for a very challenging surgery, one that a few years ago had a 10X increase in complication risk. Per our protocols the patient was offered several choices of lens implants, and the expected outcome (visual acuity, need for glasses, etc.) for each of these was discussed and explained multiple times by multiple staff members and doctors, all according to our protocols. Some of these implant choices were entirely covered by insurance, and others included fees for which the patient was responsible. These, too, were covered in detail several times by several staff members. In this particular case there was even a second, extra (no charge) visit to the office specifically to discuss these options and the associated expectations following surgery.
So how’d it turn out? The staff and doctors were turning cartwheels when we discovered that the one-day post-op distance vision was 20/20 without any glasses! Imagine our surprise and chagrin when patient and spouse sad glumly in their chairs at the news, not the least bit excited. In fact, the majority of the visit consisted of patient and spouse grilling doctors and staff about the fact that the patient could no longer see up close without glasses. This despite the many counseling sessions about implant choices and post-op expectations in a patient who could not pass a driver’s test with or without glasses prior to surgery. Not a word about how amazing it was that such a challenging surgery resulted in the ability to now pass a driver’s test without glasses!
You might fairly ask if I was amazed by this? Sadly, no, I was not. It’s not enough for the airline to bring you in on time and safely. Nope, now you had to be flown first class on a free ticket and arrive early to simply be satisfied. To be amazed one would need to have somehow been transported to and from the S.S. Enterprise by Sulu personally.
Manned flight, up and down with nary a hiccup each and every time. Cataract surgery that improves your vision 99.9% of the time with nary a hiccup. Joint replacements that allow you to play tennis. GPS in your car that directs you to within a foot of your destination. Neurosurgery while you are awake. Cell phones, for Heaven’s sake! Sometimes you fly first class or see 20/20 without wearing your glasses! Come on…that’s amazing! Right?
CrossFitters have taken up the cause of health, given the charge of improving health and preventing decrepitude. There will always be a need for what we can call “real medical care” or sickcare (you know, rather than healthcare). After all, stuff happens. I’ve been plunged into the abyss of American sickcare as I help shepherd my Dad through a prolonged exposure.
Much has been made of the tremendous costs of the most modern medical care. There was a 20 page article (20 pages!!) in Time magazine about this last week, about inflated charges and financial gamesmanship and whatnot. True enough. Indeed, I’ve read the theory that sickcare in the U.S. was pretty darned good 10, 20, 30 years ago, and we spent much less money for it back then. Why not just use, say, 1980′s sickcare as our standard? Weren’t we pretty healthy then? It sure seemed like we could at least afford sickcare then, both on the personal and societal levels.
Here’s the rub: I saw 2013 vintage care this week, and I saw something that approximated 1985 or so. The “time travel” between 1985 and 2013 was a real eye opener. No one in their right mind would trade the best of what we have today for “1985 is good enough”. Trust me. That particular “time travel” trip was a nightmare.
Do we as a society, country, and/or economic ecosystem need to find some way to bring some sanity, some rational economics to how we buy and pay for our “sick care”? You bet. We here in the CrossFit world are on the right track as we seek health, seek to avoid the need for sickcare. But man, I gotta tell ya, if you are sick and you need to be cured, you want to be right here in North America.
And you want to be be here today, in 2013.
“Eating healthy is too expensive.” How often have you heard some version of that phrase. Whether it be Zone, Paleo, Whole 30, or just “stay out of the middle of the grocery store”, this is uttered with some degree of exasperation and oppression with a kind of mind-numbing, self-fulfilling frequency. There is an overarching sense of deprivation here, a feeling that it’s just impossible to find the money to eat lean protein or fresh fruits and vegetables.
How so? Per the folks at Whole Foods, regularly skewered for being too expensive (seriously, they sell fancy potatoes), on average we in America spend 7% of our disposable personal income–that’s SEVEN–on food. 50 years ago that number was 16%. We now spend less than 1/2 of our after-tax income on food compared with what we spent 50 years ago.
And eating well is too expensive.
If we dig deeper into that stat alone we see that modern food production has decreased the cost of food relative to both income and inflation. The cost of producing food of all kinds has risen much more slowly than income. Why? Partly because junk carb-laden food is cheap. High-fructose corn syrup costs a fraction of grain sugar. Corn-fed protein with or without pharmaceuticals is grown faster and cheaper than grass-fed. Stuff like that. Less expensive to produce/incomes risen over 50 years at a greater rate across the entire spectrum, top to bottom.
How then is it too expensive to eat a more healthy diet. We have 9% of our after-tax income to play with, right? Even I can do that math. Is some other necessity (shelter, transportation, medical care, etc) eating that up? What are we doing with that 9% that we can’t find some of it to eat better? Ah, Grasshopper, now we begin to see. It’s a ‘Nando thing, it’s superficial. It’s not how healthy you are, it’s how you look, or feel, or something like that.
Some stuff might be more expensive; it probably really is more expensive to put a roof over your head in Manhattan nowadays, both the Island and the Beach. The seemingly obvious culprits are actually false targets (eg. healthcare which for this audience represents only a tiny % of new cost compared with 50 years ago because of insurance, govt. programs, etc.). Nope, it’s how we CHOOSE to spend that freed-up 9% .
Think about that household in the 1960′s or even the 70′s. Average of 6 people under that roof. One car. One TV. One radio. Once purchased all data was free. A pair of shoes and a pair of boots. Sneaks if you were a jock. You didn’t get your hair done if you were a guy, you got a haircut. You didn’t get your acrylics touched up every 2 weeks; if you wanted long nails you grew ‘em. Stuff like that.
Fast forward to today and think about the stuff you’ve acquired, stuff you are convinced you can’t live without, stuff that costs money, cash that you choose to spend every single day. The ratio of drivers to cars in a household is seldom less than 1.5/1. The ratio of phones to people over the age of 10 is seldom less than 1/1, often more than 1/1 if you add in a landline upstairs, downstairs, and in every bathroom. It’s not enough to have a cellphone, or even a cellphone with an unlimited text plan, nope, it’s gotta be a SMARTphone that will let you post your thoughts on today’s weather in Bimini to FB. Right now, from anywhere. If you don’t have Netflix available on each of the 4 flat-screen TV’s in the house you are considered a Luddite.
Listen, I certainly am not saying that all that stuff isn’t great, that it’s not a ton of fun and really convenient (as I type on one of the Apple products that literally litter our household, through my WiFi network, in front of my LightBright lamp, in the bathroom), or anything like that. What I most certainly AM saying, though, is that people who whine about how hard it is to afford to eat better almost always do so via a FB post from their iPhone 5 while sitting in the salon having their hair done, hungover from too much Bellevedere they consumed last night while noshing on Doritos smothered in Cheez-Wiz.
9 %. The stark reality is that we have let our things become more important than ourselves. We are choosing Apples alright, just not the ones we find in the outer aisle of Whole Foods.
I’ve been thinking a lot about health care recently. Real health care, not Health Care as in “Health Care Crisis” or “Health Care Reform”, but the kind of health care that is provided by doctors and nurses and all kinds of other health care providers. You know, like making sick people better, and keeping healthy people healthy. The kind of health care that old guys like me (I’m 52, in case you were wondering) got from pediatricians like Dr. Roy in Southbridge, MA in the 60′s, or like my sons get from Dr. Gerace in Westlake, OH today.
I did a lot of thinking about this some 7 or so years ago, too, when I developed the concepts that eventually resulted in Skyvision Centers. My mini-epiphany at that time is that medicine is the ultimate consumer service business. At its core medicine is about one group of people providing a service to another group of people who either want or need that service. It’s the most intimate type of service, too. One to one. Face to face. You and me.
There is a remarkable lack of difference between doctors (and hospitals, for that matter) when you look at the outcomes that arise from that service– how many people get better after receiving medical care for their illnesses. The difference between the top 1 or 2% of doctors and the 50th percentile in terms of real medical outcomes is remarkably small, and much smaller today than it was in the days of my Dr. Roy.
Sure, there are differences in how people arrive at getting better. Some very instructive studies from Dartmouth have shown dramatic regional differences in the U.S. in how much money is spent on treating heart attacks, for instance. By and large, though, the same number of people get the same amount of better no matter where they are treated or from whom they received that treatment, and the quality of those treatments is several orders of magnitude greater and better than it was in my youth.
So what was it about Dr. Roy that people in my generation seem to have so much trouble finding in medical care today? If the treatment of diseases is so much better now why do so many people complain about medical care today? Why is it that Dr. Gerace has people lined up waiting to see him while other doctors don’t? Why do people rave about their experience at Skyvision Centers and complain so bitterly when they need to have a consultation at some of the most famous medical institutions in Cleveland?
I think it’s because Dr. Roy, Dr. Gerace, and I were all, once upon a time, caddies.
Seriously. We spent the earliest part of our working lives on the lowest rung of the service ladder, providing one-on-one service for a single customer. Because of that I think each of us realized that what really sets doctors (and hospitals) apart is what a patient experiences when they visit. The most successful doctors and the most successful medical practices are those who have realized that the central character in the play is the patient. The most successful caddies never forget that the most important person on the course is the golfer. The job of the caddy is to help the golfer perform a well as possible (maximize the health of her game) while at the same time making sure that she has a wonderful experience on the golf course.
Ben Stein wrote a column in the NY Times about his first real job; he was a shoe salesman. Imagine, at 17 years of age, selling shoes. Days filled with all manner of customers and handling the foot of each and every one of them. Customer service and sales is “learning the product you are selling, learning it so well that you can describe it while doing a pirouette of smiles for the customer and talking about the latest football scores” no matter who that customer might be. Tinker, tailor, soldier or spy, junior partner or janitor. Be they humble or haughty, gracious or grating. Totally focused on that one customer in front of you in order to provide them that service. The same can be said for any front line service job. Waitress in a diner, car mechanic, you name it.
My first summer job was caddying, and I caddied for parts of each summer through medical school. As I think about it now after reading Stein’s article it’s amazing how many parallels there are between my first job as a caddy and my career as an eye surgeon. I toted the bags for one or two golfers at a time; I usually have a patient, patient and spouse, or parent and child in the office. I was a better golfer than almost all of the men and women for whom I caddied; I know more about the eye than every patient who visits, google notwithstanding. In both circumstances my success was/is determined by my customer’s (golfer/patient) outcome, their “score”, as well as their view of the experience. Even a career-best round doesn’t feel quite as enjoyable if it took place over 6 hours in the company of a surly caddy!
I’ve told the story of how being a caddy turned into Skyvision Centers; it’s a neat story and I love telling it. For the moment, though, I have a little experiment for anyone who might be listening, and a modest suggestion for the powers that be in medical education (who most assuredly AREN’T listening). The next time you visit a doctor ask him or her what their first couple of jobs were. See if you can predict which of your doctors or dentists (or nurses) had what kind of jobs before their medical career based on the kind of experience you’ve had in their offices or institutions.
Let’s add a little time to the education of the folks who take care of our medical problems, especially our doctors. How about 6 months selling shoes at Nordstrom’s. Or a year of Sunday mornings slinging hash at a local diner. Better yet, let’s get all of those pasty washed-out interns out on the golf course with a bag on their shoulder and a yardage book on their hip, golf hat slightly askew and Oakleys on tight. Let ‘em learn how to take care of a customer without the huge advantage of all that medical knowledge. We’ll take the best of them and turn them loose in offices all across the land. Those who can’t hack it, the ones who can memorize the history of Florsheim but can’t bring themselves to touch a foot, who are scratch golfers but can’t bring themselves to congratulate the hacker who sinks a 30 foot double-breaker, those we’ll hide in the lab, or put them in huge, anonymous medical centers, one more anonymous member of an anonymous team hiding under the brand umbrella of some “World Class Clinic” where one-on-one customer service never really happens.Because the ultimate consumer service business is medicine.
Just ask a caddy.
Apple just released a smaller Tablet, the iPad Mini, and was razzed by the cognoscenti because it broke no new ground. “Reactive.” “The first time Apple plays defense.” “Nothing to see here, people. We’re walking…we’re walking.” While the Apple Fan Boys (and Girls) were lining up to add to their Apple quivers, the rest of the consumer world reacted with a communal shrug. Why? No real innovation, and that was a surprise in the world of consumer electronics recently dominated by Apple’s serial innovation.
It makes you wonder a bit, doesn’t it, why there’s so little innovation in the world of medicine when it comes to the storage and transfer of information. With all of the cool stuff already available (voice recognition, “pens” that convert script to text, intuitive “next step” software), why do we have such stodgy, clunky software attached to yesterday’s hardware in all of our EMR choices? For heaven’s sake, we don’t even have a universal platform upon which the various and sundry products are built, and so we continue to have interoperability issues more than 10 years after folks started putting this stuff into play. Why is that?
Every computer product I’ve bought and used over the last 10 years has been easier to use than the one it replaced. Each one has allowed me to do more, and usually with a smaller and less expensive gadget. I know it’s a cliche by now, but my phone has more computing power than the first SERVER I bought to run an entire medical business. For $400. I can talk to it, order it to do stuff, and get all kinds of help I never needed faster than I could realize I needed it, and it fits in my pocket. Yet in a medical office state of the art consists of serial drop-downs and mandatory field entries that may or may not include anything germane to my patient. Able to chat with my cell phone through a bluetooth headset, my EMR demands my full, undivided attention, with gaze fixated on screen.
In the world of consumer electronics the game is all about predicting what the next, big “gotta have it” gadget or service will be. The most exciting and successful products almost invariably carve out new territory and then go on to viral-like growth because they fulfill a need. This kind of technological progress is so powerful that the people who buy this stuff abandon perfectly functional gadgets that do everything one needs or wants in favor of that next, new-better gadget. This phenomenon in turn drives the makers of consumer electronics to create, to innovate. But not in medicine.
Why is this so?
The so-called “market” for EMR is simply non-existent. The power of innovation, either in response to consumers established, stated needs and desires or in anticipation that something new and better will simply take off in the marketplace is non-existent. The kinds of companies that seemingly come out of nowhere were bludgeoned by government mandated requirements that tiny, bootstrap companies just couldn’t fund the effort. Big companies that innovate like a tiny start-up and create whole, new categories, like Apple, simply didn’t. They all just doubled down on old tech and old ideas, an entire industry making iPad mini’s and calling it progress. The perceived danger of innovating and then having a revolutionary product found to lack “meaningful use” stifled the entire industry. Innovation in EMR was DOA.
And now? Now we have the largest medical institutions in the country abandoning their own efforts at software development and marching like lemmings to the Epic sea. The real-world analogy would be the government saying that you could create any type of gadget you could think of to listen to music, but you can only sell record players and vinyl albums on which you must listen to the songs in the exact order in which they appear on the disc to be assured that the check would clear. Oh, and the doc or nurse could only listen through noise-cancelling headphones that would need to be removed in order to talk to a patient.
It doesn’t have to be like this, of course. All it takes is one company with a little vision and some gumption to find a single big-name player with the courage to see that the status quo is sick. Sure, the vast governmental bureaucracy needs to fix a target and then get out of the way so that something that looks like a real consumer electronic product can emerge. That’s all, really. One product that feels like as “0f course” as the iPod, discovered and purchased by one person who folks watch like TechCrunch, a dispassionate and largely uninterested government standing to the side, idle.
A 7″ computer that could power my company 7 years ago hits the market to a collective yawn? Is it really so much to ask for this type of innovation in EMR?
OK, so maybe this part was my fault. I probably would be a bit better at this Epic thing if I did it more frequently than once every two months. Guilty. The thing is, though, that every little thing Epic asks me to do has either already been done on paper, would go faster if it was done on paper, or both.
It takes two discreet steps to enter the software program, even if you are in a CCF institution and working on a CCF computer; it’s even more complex and takes three steps from the comfort of your own computer. I get the security thing; really, I do. I tried it both ways and failed. Epic failure. Again. So once again I had to call in the cavalry in the guise of the physician support team just to get into the system, finally achieving this milestone event after 3 attempts and a total of 100 minutes of work.
Success, right? I’m in. Nothing to do now but clean up my charts, sign this, attest to that, and away I go. Sure…about that. In the interim between my visits there’d been an upgrade, ostensibly to make using Epic easier. Another 45 minutes of frustration ended up in another phone call and a personal visit by one of the support staff to guide me on my adventure. Kinda like being roped to a mountain guide when you really have no business climbing that particular mountain, except on the mountain you chose to be there.
You’re probably wondering why there was such a big interval between my visits to the “mountain”, and why I chose to continue my Epic adventure now. Both have rather simple answers. I hate everything about this process and this program; I feel oppressed, literally, forced to use a bloated, inefficient bureaucratic load of “make-work” that adds nothing but time and effort to my day, and so I naturally avoid it for as long as possible. How long? Well, long enough this time that the reason I found myself roped to my guide was the Registered Letter informing me that I’d ignored all of the notifications that I was delinquent in my charting and had therefor “voluntarily resigned” my staff position. Another 30 minutes with my guide and my slate was clean.
How, you might ask, had I possibly allowed myself to “voluntarily resign”? I’ve been a doc for some 25 years; I know the medical staff rules. I’ve been signing charts forever. My address, fax number, and email are all unchanged, and I’ve never missed a notification from the hospital before. Despite my obvious, transparent disgust with Epic and everything it imposes on me, it doesn’t make any sense to let that jeopardize my ability to do surgery at this institution by petulantly ignoring my medical staff requirements. How did this happen?
Easy. All of the notifications were messages only available when you log into Epic.
“Well Hannah, we really think ABC, Inc. is poised for a big uptick. We see them riding a strong secular tailwind in the 3rd quarter with earnings to follow”
Excuse me? “Secular tailwind?” Seriously, WTF is a secular tailwind? Does the presence of a secular tailwind mean that there must be a secular headwind hiding out there somewhere? And how about the “secular” part of this weather front? Secular always seems to be accompanied by sectarian. You know, like Sunni’s and Shiites. The yin to someone’s yang. Heathens and infidels on one side, true believers on the other. If a “secular tailwind” is good, how bad is a “sectarian headwind”?!
For those of you who haven’t been paying attention, I not only play a doctor on TV, I also play one in real life. We doctors have been vilified for using impenetrable language to make ourselves look oh so very smart, all the while confusing the heck out of our patients and making them feel unintelligent. Small and embarrassed. Kinda like when you ask the wine steward for a suggestion and you just know… you KNOW… everything he said about the wine was pure nonsense, and your wallet’s about to get violated. Heck, at least we doctors had the decency to use opaque phrases in a different language. We really sounded pretty cool and very smart when we said everything in Latin or Ancient Greek.
Not the good folks in finance, though. The don’t even really SAY anything. They’re just making S__T up. “Secular Tailwind.” Seriously, how do they say stuff like that and keep a straight face? Maybe it has something to do with the fact that everyone who watches or listens to those financial shows is doing so by choice; unlike a patient in his doctor’s office who has some kind of illness to be sorted out, the people watching CNBC or MSNBC are voluntarily tuning into Cramer and his buddies. Not a soul in that audience needs to be listening. Their reward is to be insulted.
It turns out that the relative “literacy” rate for medical information is roughly akin to the vocabulary of an eighth grader. In other words, if I choose to use words or phrases that would not register with the average eighth grader a substantial percentage of my patients will not understand what I am trying to get across. Real research has been done on this stuff and reasonably so; it’s important to understand what your doctor is trying to tell you. Many of us in medicine really do get this, and really do try to neither speak above or speak “down to” our patients. Gone are the days of multisyllabic jargon sandwiched between words from a dead language.
Imagine if that wasn’t the case. Even worse, imagine what it would be like if physicians and other caregivers acted like all those financial talking heads and not only tried to confuse you but just blatantly made crap up while doing so. “Well Mrs. Jones, I’m afraid there’s a involitional reservoir of hard fluid residing in the retrosplenic attic which appears to have suspended all glomerular transport underneath. There are a number of ways it could have gotten there, and of course there’s no guarantee that we are right, but we are pretty sure it was blown there by a Secular Tailwind.”
Don’t worry, though. We’ll just start a little IV Novena…
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