Friday, October 29, 2004

Still No Vision for IT in Health Care

Anyone who wants to understand why the health care system has been so slow in exploiting information technology needs to look no farther than the round table discussion reported in the October 2004 issue of the journal H&HN (Hospitals and Healthcare Networks). With the sponsorship of GE Healthcare, The American Hospital Association and its subsidiary Health Forum convened a panel of 11 health care leaders, including several CEO’s of major health care institutions, to discuss “The CEO and the Future of Technology” with “technology” in this case referring to information technology.

Reading the report, it occurred to me that there must have been a day in some airline company when a senior executive became aware that computers made it possible to save big chunks of money by getting passengers to make their own reservations, write and pay for their own tickets, and issue their own boarding passes.

Similarly, there must have been a day when Sam Walton realized that computers would allow his suppliers to monitor the sales of their products in Walmart stores and manage Walmart’s inventory of their products. This would make hordes of buyers and inventory clerks redundant while making sure that store shelves were always stocked.

The introduction to the H&HN report talks about the CEO “shaping the direction of…..information technology for the organization.” That is not what the airline executive and Sam Walton did. They shaped new and previously impossible directions for doing the work of their organizations and used information technology to make it happen.

An example in of such a vision in health care would be to have Physicians’ Assistants and Nurse Practitioners provide direct care to heart attack patients, using computer-supported protocols remotely monitored by cardiologists, thereby reducing cost and improving quality. This is essentially the prevailing arrangement in Emergency Medicine, where technicians provide direct care and treatment in the field with backup from doctors who remain at the hospital.

There was nothing in H&HN report to indicate that the people on the panel had anything of this nature in mind. But until they do, the application of IT in health care will be mostly for show with high costs and low returns.

Tuesday, October 19, 2004

More Dollars for the Healthcare IT Sinkhole

I see that the U.S. Department of Health and Human Services (HHS) is making grants of $139 million “to speed adoption of health IT.” (AHA News Now, October 13, 2004) Awards will include “more than 100 grants totaling $96 million over three years to communities, hospitals, health care systems and providers in 38 states to support health information technology use and development, particularly in small and rural hospitals and communities.”

IT is a useful tool because it allows things to be done better and cheaper. That being the case, one might suppose that the health care system wouldn’t need any subsidies or governmental encouragement to take advantage of it. The little country bank in Harlan, Iowa where I have had an account since childhood recently offered me on-line bill paying capabilities. Free. I assume it did that to eliminate the cost of processing paper checks. So far as I know, it didn’t wait until the government gave it some money to do it.

Doing things better and cheaper means changing the way you operate. But change creates winners and losers, which involves a certain amount of pain. In the case of health care (which operates in much the same way it did 50 years ago) it involves a lot of pain, and so there is great resistance to doing it.

Creating an IT application requires a financial investment, which adds the pain of paying to the pain of change. Not wanting to look inefficient and backward, health care has been willing to endure the pain of paying, but not the pain of change. So there have been a number of grand announcements of major IT projects, with few reports of positive outcomes and the occasional embarrassment of major failure.

HHS’s IT grants will certainly alleviate the pain of paying but is unlikely to do much to induce the health care system to endure the pain of change.

I believe the first IT project of this kind of which I was aware took place sometime around 1960 at the University of Arkansas Medical Center. As best I can recall, it was a grant-supported attempt to automate pharmacy operations. So far as I know, not much came of it.

Maybe it will be different this time, but I doubt it.

Friday, October 15, 2004

No Pain, No Gain

During my high school days, I ran a little track – nothing outstanding but enough to earn a letter. My coach told me that the way to get into shape was to run as long as I could, and then run another lap. That was my orientation to the physical conditioning concept of “no pain, no gain.”

The concept may have an application to health care. Years of being pampered by public adulation, professional independence, cost reimbursement, certificate-of-need protection against competition, and the like have left the health care delivery system too flabby to cope with the issues of access, cost and quality.

The pain of getting in shape goes some distance towards explaining why government is so poorly suited to leading the process of health care reform. Elected officials avoid anything that might cause their constituents discomfort. This reluctance may explain the observation by the ever insightful Emily Friedman in the September 27, 2004 issue of Modern Healthcare that health care policymakers have not only avoided the issue of healthcare inflation, “they have actually moved to preserve and even increase it.”

Politicians will be the last to annoy people by telling them that they cannot have complete freedom of choice of physician and that the physicians they choose cannot be free to practice unnecessarily expensive medicine that does not conform to best practices. More frequently they will be found promising the opposite.

Neither will they upset doctors by insisting that their practices come under institutional supervision, mainly by hospitals.

Yet all of these are fundamental to achieving the discipline and accountability that are central to health care reform.

In the market driven parts of the economy, enterprises that don’t perform don’t survive.

Maybe market competition is not the best way to reform health care, but so far nobody has come up with a better one.

Sunday, October 03, 2004

ED Congestion and Dissolving Boundaries

As I have followed recent press articles about overcrowded hospital Emergency Departments (ED’s), my thought has been that the obvious solution was to expand them.

Apparently I was wrong. (No surprise. It has happened before.)

The Summer 2004 issue of Frontiers of Health Services Management features the Institute for Healthcare Improvement (IHI) and the techniques it has developed for improving flow through acute care settings, in this case, ED’s. In applying these techniques, IHI has found that ED’s are being clogged up less by what comes in their front doors than by what they are unable to move out the back. So expansion won’t help. Enlarging the entry doesn’t shorten the queue at the exit.

The problem is expressed in terms of variation, three types of which are identified:

First, there is variation in the numbers, arrival times, and conditions of patients coming for care. Second, there is variation in staff competency and clinical abilities. These two are called natural variation. They are inherent in any situation and are to be managed.

The third type of variation arises “from personal preferences and beliefs of individual clinicians.” The authors call this artificial variation and say that it needs to be eliminated. They say “The effect of artificial variation on flow far exceeds the effect of variation resulting from random, highly complex disease presentations.”

In other words, the hospital (including its medical staff) is the source of the problem, not the patients.

Two cases are then described in which application of the IHI techniques has successfully relieved ED congestion.

What I found striking in all of this was the absence of deference to the special status of doctors and the lack of respect for the traditional boundary that prevents hospital management from interfering in medical matters. Particularly audacious was the blunt statement that variation in the preferences and beliefs of individual doctors needs to be eliminated! (emphasis mine) It hasn’t been long since a remark like that could get somebody fired.

This may well be the best example yet of how the health care system must learn to manage the patient care process as a totality; i.e., including the practice of medicine, if it is to successfully control cost and achieve uniformly high levels of quality.

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