Sunday, December 17, 2006

clinical innovations, human vignette4s, Twenty Clinical Innovations to Build Patient-Doctor Trust: Fourth in a Series

On Technology and the Nature of Human Nature

Today's message is: Behind every health care innovation lies a human-technology vignette.

In my first three entries, I spoke about innovations and improving human interactions – how doctors can innovate through anticipating those magic moments of patient expectation and paying attention to nurses.

I did not speak of the technological nature of most health care innovations. But let’s face it. Most health care advances, no matter how small, occur through blending human need and a technology to fill that need.

Don’t take my word for it.

Five years ago, Victor Fuchs, PhD, Professor Emeritus at Stanford Business School, and Harold Sox, Jr,, MD, former chair of the Department of Medicine at Dartmouth and editor of Annals of Internal Medicine, wrote an article in Health Affairs reporting on the views of 225 general internists on the relative importance of 10 major medical innovations.

Physician Choices of Top Ten Innovations

Here are the internists’ rankings of the top 10 medical innovations, all of them technological in nature.

1. MRI and CT (magnetic resonance imaging and computed tomography).

2. ACE inhibitors –treatment of high blood pressure.

3. Balloon angioplasty – a procedure to open blocked blood vessels of the heart.

4. Statins – drugs used to improve lipid metabolism and reduce risk for coronary heart disease and other vascular diseases.

6.Coronary artery bypasses graft.

7. Proton pump inhibitors and H2 blockers – used to treat gastro-esophageal reflux disease.

8. SSRIs (selective serotonin re-uptake inhibitors) and new non-SSRI. Anti-depressants.

9. Cataract extraction and lens implant.

10. Hip and knee replacement.

Technology Not Management or Social Innovation

These are technology innovations, rather than social or organizational innovations. Most innovations (except for MRI and CT, originally developed in England), originate in the United States.

We are a nation of innovators. Over the last 30 years the United States has produced more medical Nobel Prize winners than all other nations combined; drug companies headquartered here have created eight of the ten selling drugs; and, in the 30 innovations listed by Fuchs and Sox, eight of ten came from the U.S.

These technological innovations’ downsides are high costs, and in some instances, unregulated entrepreneurialism (the operative words criticizing those who profit is “greed,” and for those favoring profit is “opportunities”) on the part of manufacturers and physicians users of these wonderful innovations. American patients are often willing accomplices to overuse, for they, like their doctors, have insatiable appetites for medical technologies as a “quick fix” for their ailments.
Consensus of Health Care Stakeholders

I recently polled 100 health care stakeholders – hospital executives, physicians, consultants, editors, and contributors to this book and to my previous books. I have asked them to rank the ten innovations in order of importance. Here is the consensus.

Top Ten Innovations – Consensus among 100 Health Care Stakeholders

1. Pay-for-Performance (P-4-P) programs

2. Introductions of electronic health records (EHRs) into medical practices.

3. Add-ons to EHRs – instant medical histories, coding devices, prescription-enabling modules, or websites that permit registration, virtual visits, prescription refills, open-access scheduling.

4. Software that facilitates office dispensing and prescription writing.

5. Self-care, self-service, and self-empowerment of consumers.

6. New practice business models ( concierge, cash, or other new types of innovative practices, such as retail clinics or home disease management )
7. High tech/high touch remote patient monitoring with patient interactive capacity.

8. Personal Health Records with and without EHRs.

9. Disease management programs.

9. The transparency movement as part of consumer-driven care movement.

Again most of these innovations are technological, but in this case, observe that the technology focuses on the digital revolution and how it can be used to blend and bind humans together.

An Example of Human-Technology Blending

In closing, let me offer an example of this blending and binding.

Fifteen years ago, Dr. Allen Wenner, a family physician in Columbia, South Carolina, was trying to figure out the clinical puzzle of an older woman with multiple complaints, including dry mouth and dry eyes. He referred her to a medical center, where a medical student spent hours with the patient, and with the help of the medical school faculty, diagnosed Sjogren’s syndrome, a chronic disease affecting many organs, and causing fatigue and marked by dry eyes and dry mouth.

Wenner remarked at the time, “If only I had time to listen to her entire story, I could have figured it out.” He reasoned that if she had told her story to a computer in a systematic and narrative way, guided by her chief complaints of dry eyes and dry mouth and by clinical logic, he would have quickly nailed the diagnosis. By telling her story to a computer, the time spent would have been her time, not his. Furthermore, she would not have minded telling her full story in the form of ‘yes” or “no” answers in response to a simple clinical algorhythim.

Wenner and associates set about developing hundreds of these algorhythims based on patients’ chief complaint, gender, and age. The result was a piece of software called the Instant Medical History, which most patients (more that 90 percent) can complete from their home computer or on a laptop in the reception room before seeing the doctors.

Patients, as it turns out, like telling their complete story (even if to a computer), and doctors like reading the narrative. It tells the patient’s story, helps them immediately zero in on the chief complaint, documents the story logically, and makes for a completely documented story of the clinical encounter, which the patient can take home upon leaving the office.

More than anything else, the Instant Medical Record saves 5 to 8 minutes of time for each patient encounter. Waste of time – in waiting for an appointment, in the reception room, and the exam room – is the bane of modern medicine, of busy patients, and harassed doctors.

As Peter F. Drucker, father of modern management, observed:

“Time is a unique resource. One cannot rent, hire, buy, or otherwise obtain more time. The supply of time is totally inelastic. No matter how high the demand, the supply will not go up. Three is no price for it and no marginal utility for it. Moreover, time is tally perishable and cannot be stored. Yesterday’s time is fore forever and will never cameo back. Time, is therefore, always in exceedingly short supply. Time is totally irreplaceable”

And as Sir William Osler, father of modern medicine, noted:

“Listen to the patient, and they will tell you the diagnosis.”

Time permitting, of course.

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