Several years ago, I led technology on a project for a major healthcare provider, one that was often described as “America’s largest” in its category. We were doing a project where we used web technology for disruptive innovation. It was tested in a randomized clinical trial funded by a major pharmaceuticals company and was proven successful. In our system, patients and providers interacted online for chronic disease management. Within two years, we had developed a protocol for two of the top-5 most costly conditions.
What we were doing was using the new capabilities delivered by new technology to drive process change. We recognized that more frequent engagement with patients was possible and that by empowering patients, we could help them to help themselves. Our system was proven in controlled trials to generate better outcomes, and that the (previously) sicker patients used our system more–and derived more benefit.
That company failed through a strange sequence of events, starting with the arrest of a former national rugby player in New Zealand that triggered a fall in a stock price. After a fairly orderly wind-down, I left and started working with mainstream health IT.
Mainstream health IT kills the joy of new technology. Instead of using technology as an engine of process innovation, it uses powerful systems to automate old, inefficient processes. Look at Athenahealth, for example. Their whole, brilliant model is that they hide from providers the ugly workings of the system of payments in care — but that ugly system is still there, and, to some extent, Athenahealth enables it. When I talk to providers about EMR systems, I hear about “alert fatigue,” I hear about crazy security procedures, and I hear about a total inability to get access to useful information in a sea of data. The system is locked in what looks like a Nash equilibrium: any step towards sanity by one player (payer, provider, facility, etc.) would be jumped on by the others as an opportunity to take a bigger piece of the pie. When Intermountain Healthcare’s Brent James standardized lung care for premature babies, they cut ventilator use by 75% — and lost $329,000 in revenue. When I see outcomes from health IT adoption, the cost savings are typically less than taking the initial investment and putting it in treasury bills. When you add to this that in healthcare, typically a cost savings is paired with lower revenue (providers are paid for providing), health IT is a losing proposition.
I spend a lot of time thinking about the art versus the science of care. The true artists of medical care don’t need health technology, and they don’t need much else. With a brilliant, say, neurologist, one look and s/he can tell you what medications, physical, and occupational therapy the patient needs. The science of care is more plodding, involving a process of neurological, PT, and OT evaluations and a meeting afterwords to discuss. Sad as it may be to those who watch prime-time medical shows, most of us would benefit from systematizing the science of care, rather than hoping to find an artist.
Here’s where the tech comes in: instead of thinking about how the process is, we need to think hard about how the process should be, in the context of pervasive, always on, always available information systems. A brilliant cardiologist seeing a patient with chest pain may remember everything to look for and may be able to do off-the-cuff dictation. Generalists might not. Information technology can augment their clinical encounters, and, just as importantly, guide their clinical notes to ensure that relevant information is recorded with sufficient context to allow it to be not only read by the next provider but indexed by the system, for use in quality programs or to automate panel analysis (e.g., for a new clinical trial).
The jump from paper to online systems, whether in medicine or government, is a radical leap. It is foolish to effect this change without taking a similar radical leap in processes. Even if processes, policies, and procedures were perfectly optimized in a paper-based world, they will fall far short of capturing the potential of a digital one. I’ve seen some of how a radical change in thinking, leveraging new technology, can revolutionize the healthcare experience. It’s time that we drive this change into mainstream care, and, in so doing, transform care from a 19th century model to a 21st century one.
