Tuesday, March 20, 2007

Electronic medical records, health care general , fable -Two Elephants and Six Blind Men

The elephant in the living room is what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.

David Brailer, MD, February 15, 2005, as quoted in The New York Times by Steve Lohr, “Health Industry under Pressure to Computerize

Our health care system is as huge and cumbersome as an elephant, and all the players — like the blind men in the story — see the elephant differently. Doctors holding the tail perceive the system as constraining as a rope, purchasers touching the leg find it as immovable as a tree, and plans holding the trunk see it as devious and unmanageable as a snake.

We're blind to the system's true shape, and what we can't see is killing us. It's also crushing us financially, but we can't move it — can't fix it — until we can see it. The system is opaque, abstruse, variable, incredibly complex, and weirdly fragmented. Its very nature makes vision of the whole impossible, say experts.

Martin Sipkoff, “Can Transparency Save Health Care? “Managed Care Magazine, 2004

Just over two years ago, David Brailer, MD, then national health information coordinator for the U.S. Department of Health and Human Services, commented small practices were the “The Elephant in the Room.”

He meant that unless small practices adopted electronic health records, the government’s plan to establish an interoperable computer system linking all U.S. health system components might fail.

At the time Brailer made his remarks, among groups of 50 or more physicians, two thirds (68%) had adopted electronic health records. For groups of five or fewer, only 12% had EHRs, and among solo doctors or doctors in groups of two, only 1% had such records. Yet these small groups of five or less made up half of practicing physicians in the U.S.

Past and Present

I was reflecting back on the “Elephant in the Room” when I ran across this paragraph in the “In Brief” section of the March 19, 2007, issue of the American Medical News.

A survey by the consulting giant Accenture finds that two-thirds of patients say the use of electronic medical records is an important factor in choosing a physician – and half say they would pay a “reasonable” extra fee to see a physician who uses them. Meanwhile the same survey found 11% of physicians using EMRs. Accenture surveyed 600 patients and 100 doctors.

Apparently, independent patients and independent doctors don’t always see eye-to- eye.

Independent Patients

Meanwhile I came upon this paragraph in the March 15 Online Wall Street Journal in article bearing the title “Many Americans Disregard Doctors’ Course of Treatment”.

A quarter of America’s patients have a drug prescription unfilled because they felt it was unneeded and a fifth obtained a second opinion because they felt their doctors recommendations were too aggressive

The Wall Street Journal piece brought to mind to report by the Boston Consulting Group in 2003 Finding a Cure for Unfilled Prescriptions and Missed Drugs.

Briefly that report indicated 33% of patients took drugs less often than prescribed, 25% said they delayed taking the drug, 20% stopped taking the drug because of perceived side-effects, 17% said the drugs were too costly, and 14% believed they didn’t need the drug,

They viewed themselves, not their doctor, as the ultimate judge of what drugs they need. Fully 24% said “forgetfulness” had nothing to do with their failing to comply (italics mine). Apparently independent patients felt perfectly capable of making judgments about their own care, regardless of what their doctors said.

In the same time frame, a March 16 piece of mine (not to be confused with piece of mind) appeared in Healthleadersmedia.com news, "Pay for Performance and Quality Outcomes: Buzz, Metrics, and Human Nature." I said patients often act independently when outside the doctors immediate sphere of influence. Consequently, I reasoned, pay for performance for clinical outcomes in the outpatient arena wasn’t likely to cut costs or improve long term outcomes. Americans’ penchant for individualism and deciding for themselves what was best for their health isn’t necessarily good for their health.

Dispersed Care by Multiple Practitioners

Meanwhile, the March 15 edition of New England Journal of Medicine contained an article “Care Patterns in Medicare and Their Implications for Pay for Performance” by a group from the Center for Studying Health Care Change in Washington, D.C,, and an editorial “Paying for Care Episodes and Care Coordination” by Karen Davis, PhD, head of the Commonwealth Fund in New York City.

Here are the results and conclusions the group from the Center for Studying Health Care Change reached after studying 1.79 million fee-for-service Medicare beneficiaries.

Results: Beneficiaries saw a median of two primary care physicians and five specialists working in four different practices. A median of 35% of beneficiaries' visits each year were with their assigned physicians; for 33% of beneficiaries, the assigned physician changed from one year to another. On the basis of all visits to any physician, a primary care physician's assigned patients accounted for a median of 39% of the physician's Medicare patients and 62% of Medicare visits. For medical specialists, the respective percentages were 6% and 10%. On the basis of visits to primary care physicians only, 79% of beneficiaries could be assigned to a physician, and a median of 31% of beneficiaries' visits were with that assigned primary care physician.

Conclusions: In fee-for-service Medicare, the dispersion of patients' care among multiple physicians will limit the effectiveness of pay-for-performance initiatives that rely on a single retrospective method of assigning responsibility for patient care

An Elephant Poem

These results and conclusions, showing that patients, acting independently, often chose multiple physicians from whom to receive care, led me to look up the poem by John Saxe (1816-1887) on an Indian legend of six blind men who felt different parts of an elephant’s anatomy.

I‘ve modified the poem for this essay’s purposes. Think of the six blind men as various health system fix-it gurus, each in their own way seeking Nirvana, and the elephant as a conglomeration of interacting independent doctors in small fee-for-service practices and their independent patients, the combined mass of which comprise our health system’s bulk.

The Six Blind Men of Nirvanastan and the Health Care Elephant

There was six men of Nirvanastan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind),
That each by observation
Might satisfy his mind.

The First, A Universal Coverage Sage,
approach'd the Elephant
And happening to fall
Against his broad and sturdy side,
At once began to bawl:
"God bless me! but the Elephant
Is very like a wall!"

“The sage roared, it’s clear what all we need to do.
It’s my comprehensive compassionate moral view,
That we put all inside and behind a common wall,
For this, everyone will be held in absolute thrall.”

The Second, A Market-Medicine Man,
feeling of the tusk,
Cried, -"Ho! what have we here
So very round and smooth and sharp?
To me 'tis mighty clear,
This wonder of an elephant
Is very like a spear!"

“It’s obvious to me what must be done,
Make all patients consumers to be won,
When they seek lower prices at the spear of care.
Price shopping will make care fair and square.”

The Third, An Ivory Tower Elitist,
approach'd the animal,
And happening to take
The squirming trunk within his hands,
Thus boldly up and spake:
"I see," -quoth he- "the Elephant
Is very like a snake!"

“Hence, spake the elitist, we must end greed,
It’s clear government price controls we need,
All physicians are nothing but slithering snakes,
We simply must control the money each makes.”

The Fourth, A Consummate Capitalist,
reached out an eager hand,
And felt about the knee:
"What most this wondrous beast is like
Is mighty plain," -quoth he,-
"'Tis clear enough the Elephant
Is very like a tree!"

“Consider this huge tree’s branching side,
Health care’s an economic engine we must ride,
It accounts for one-fifth of our huge economy,
Let patients and doctors have their autonomy.”

The Fifth, A Savvy Systems Savant,
who chanced to touch the ear,
Said- "E'en the blindest man
Can tell what this resembles most;
Deny the fact who can,
This marvel of an Elephant
Is very like a fan!"

“Said he, simply fan out and apply statistics,
Manage, measure, and do the basic heuristics,
It comes down to total systems engineering.
Which will make variables go disappearing.”

The Sixth, A Practicing Pragmatist,
no sooner had begun
About the beast to grope,
Then, seizing on the swinging tail
That fell within his scope,
"I see," -quoth he,- "the Elephant
Is very like a rope!"

“Look, stop thinking in terms of some overall system,
Requiring patients and their doctors to act in tandem.
As individualists, give each of them some rope,
Each by themselves in their own way will cope.”

And so these men of Nirvanastan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right,
And all were in the wrong!

So, oft in philosophic wars
The disputants, I ween,
Rail on in utter ignorance
Of what each other mean;
And prate about an Elephant
Not one of them has seen!

Concluding Remarks

Many management and policy experts purporting to have answers to U.S. health system woes have never been inside a busy solo or small practice primary physician’s office for a day. Nor have many ventured inside the minds of independent American consumers who frequent small practices.

Consumers want the best of all possible worlds – a close personal relationship with their doctor, access to the latest in life-saving and function-restoring technologies, individual freedom with unlimited choice, high value, and low prices; and financial security – a wonderful combination in Nirvana. Physicians, by and large, want the freedom to make their own clinical judgements based on their knowledge of the patietn.

Blind experts feeling different parts of the elephant tend to think they can manage and coordinate various parts of system into one coordinated, functioning, interrelated elephantine whole.

These experts talk of imposing outside solutions, varying from: universal government-run coverage, across-the-board pay for performance, herding hordes of physicians out of fee-for-service into salaried employment inside integrated health systems, coordinating care by using patient health records and electronic health records, lumping all individual payments into bundled payments for episodes of care, assigning all patients to one single primary care quarterback, shifting costs to consumers so they will take responsibility for health and shop for the best care in one huge health care marketplace; and, of course, achieving the Mother of Nirvana Dreams – total transparency.

These management and policy experts are each partly right and partly wrong, but they often neglect patient behavioral and choice sides of the patient-doctor equation, and desire of patients to be ultimate and independent judges of their own medical care – drugs they will take, physicians they will see, and personal functional outcomes they seek.

These purblind pundits may also overestimate the power of economic incentives compelling independent doctors to join virtual or centralized integrated systems for the common and organizational good.

I don’t mean to rain on the parade of these well-intentioned experts. Many of their ideas work well under the right circumstances in certain organizations and in certain parts of this vast continental nation. But, short of massive protests in the streets filled with righteous indignation over the 47 million uninsured, or a natural disaster, a World War, or a global recession, I doubt if universal coverage, and its stepchild, or universal coordination will come soon.

Desire for independence, choice, and personal self-regulation are powerful ingredients in America’s cultural soul. Even in the face of oft-heard protests that the “system” is “broken” and needs to be “fixed,” most Americans seem to prefer a multi-payer pluralistic system – a system allowing individualism and choice among various participants.

For the near future, I expect America to continue to have a blended mix of federal, public, and private subsystems – each with its special demands, each requiring different skills and management, and each having different elephants in examining rooms.

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