Monday, September 17, 2007

Limits of technology - A Data-Doubting, Technologically-Incorrect Tale

The appropriate question is not whether there are uncertainties about epidemiological data, rather it is whether the uncertainties are so great that one cannot draw useful conclusions from the data.”

John Bailor, MD, National Academy of Science, as quoted by Gary Taubes, in “Do We Really Know What Makes Us Healthy?” New York Times Magazine, September 16, Sunday, 2007

"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."

Bruce Landes, MD, President and CEO, Southwest Physician Association, a 1300 member Dallas IPA, as quoted by Gary Baldwin, in “EMR Pushback, September 14, Healthleaders Magazine

I’m not alone, but I’m in the minority in doubting the infinite power of data and IT-technologies to transform and better the quality of American medicine and the health of the American public. IT is a tool, but it’s not a driving force that will radically change the overall behavior and practice styles of American physicians or the life and health styles of their patients.

I have an ongoing debate with Brian Klepper, PhD, a good friend, an astute health care analyst, and a pragmatic idealist. Brian says, among other things that,

• IT technology data gathering companies, using sophisticated algorithms and predictive modeling to connect the data dots between all players, will dictate the future of health care.

• The data will be gathered from multiple sources, i.e, patients, doctors, health plans, Medicare, Medicaid, hospitals, labs, imaging centers – anybody who diagnoses, treats, tests, dispenses medications – or pays for care.

• IT technologies are now in place to translate the data into market-driven and government-regulated rules that will impel doctors to follow best practice guidelines, evidence-based medicine, and quality indicators – that can be used as leverage to judge and reward high performance physicians.

• Doctors will abandon solo or small group practices to join or form large groups, corporate health clinics, multispecialty groups, in order to afford the IT infrastructure to serve as credible physicians, to be rewarded as such, and to gain access to diagnostic and therapeutic support systems to practice competent, let alone, quality medicine.

• Reliance on data will drive down costs and will change the nature of private practice by phasing out fee-for-service, which encourages overuse, and phase in salaried physicians working in teams for organizations , which will encourage compliance to best practices, and removes incentives to do more.

• At some point, more likely sooner than later, doctors will be forced to install electronic medical or health records or their online equivalents, to gain access to best practice guidelines, patient health records, and diagnostic support information.

• In the names of quality and economy, major players – employers , consumers, physicians, hospitals, health plans, labs, imaging centers – will accept data as the best and most reliable means to restabilize the system before the need for managing the eminent baby boomer chronic disease boom sets in, which will force the need for data and enforce doctors to follow what the data says and where it leads them.

• Attention to and compliance with details of best practice protocols will systematically and sometimes dramatically increase overall population health and outcomes from chronic diseases.

In other words, to use Brian’s words, “ To improve the system, we have to grab all the data wherever we can, establish two levels of medical records – personal and clinical, practice evidence based best practices, use available diagnostic support tools, and get the patients, physicians, and payers on board.”

To back up his argument, Brian referred me to a blog, e-Care, written by Vince Kuraitis, MBA, who has spent 19 years in the technological trends, and who serves as the principal and founder of Better Health Technologies, Inc, a health technology consulting firm.

Basically Kuraitis says the technologies and strategies of Google Health, headed by Adam Bosworth, VP of Google and head of Google Health, hold the key to the future.

Kuraitis, deciphering clues from Bosworth’s speeches, says the Google Health strategies are:

1. To improve and refine the current Personal Health Record to make it a comprehensive data repository gathered from everyone who ever diagnosed, treated, prescribed, or paid for patient care.

2. To give every patient, who will own their own records, an internet website, a URL, which will empower them by giving them ownership and control over their record by giving them the power to decide who can enter and extract data from it..

3. To develop data gathering mechanisms making that up to date at the “speed of light,” at the instant it is generated.

4. To develop standards to make the record interoperable and accessible and enterable by all and friendly to all, including patients and doctors.

5. To make the Personal Health Record so universal, i.e. to create such a critical mass and to be so “populated,” to have so much compelling clinical information, that its acceptance will be inevitable.

6. To deal with and overcome the “disruptive potential” from patients, consumers, physicians, employers, health plans, hospitals, labs, and imaging facilities .

Google Health, says Kuraitis, will overcome the basic problem of widely scattered health information and lack of suitable standardized formats. The result will be better patient care and lower costs, all for the great benefit of humanity.

I’m sorry, Brian, but as noble and logical as your argument is, I’m not buying in its entirety, in parts perhaps, but not overall because I contend the response, use, and abuse of privileged health care data will be, well, human.

First, total transparency is not something all health care players will buy. It’s simply not part of human nature to tell all or reveal all – in politics, daily life, human interaction, or business affairs, indeed in all domestic and foreign affairs..

Second, total data gathering, while it may be technologically feasible , is intrusive, and will be resisted, no matter how sanitized, making the time frame for its adoption prolonged and painful.

Third, data can be manipulated, like statistics, and never tells the whole story of the nuances of human interactions or the considerations that go into health marketplace transactions.

Fourth, competing health care organizations will not be wont to reveal their data to each other, which, I believes, is why most RHIOs (Regional Health Information Organizations) will either fail or be DOA.

Fifth, I remain skeptical that assiduously following best practices, meeting quality indications, or rewarding doctors for performance, while desirable, will significantly improve outcome, maybe marginally, but not significantly. Many undue outcomes are due to untoward patient behavior or reversion to old deeply entrenched habits once patients are outside the reach of physicians. In a democracy, physicians can offer evidence to persuade patients to change, but they cannot compel change.

To conclude, Brian argues for the way things ought to be in a perfect world. I seek to describe the way things are in the real world and how likely they are to be. He may be motsly right, but I am not totally wrong.


Health data and information aren’t everything. Human response is important too. A dictum of the ecology of technology is this: for every technologic or information-based advance there’s a humanistic counter response. Data alone or blind belief in it will not improve care or outcomes. Nor will total transparency, intrusive rules, comprehensive data banks, salaried physicians, sophisticated clinical algorithms, or real or virtual groups practices. Improving care will take time and human understanding of the physician and American culture.

1 comment:

Davis Liu, MD said...

Physicians in many ways are scientists. On a daily basis we are posed a problem (patient encounter), do research (history taking and physical), form a hypothesis (differential diagnosis), and then begin treatment and/or get additional testing to further support or refute our diagnosis. We do this tens of thousands of times throughout a career.

As scientists, however, we need data. Having readily available data and minimizing the amount of time searching and collecting data will improve health care as physicians will have actionable information real time instead of hunting for a lab result with paper charts. With this information on hand, doctors can care for patients right at the point of care, whether in the office or at the bedside.