I also laid out the differences between effectiveness and efficiency (which the panel focused on) and productivity, which seems to have slipped through the cracks. But before we get on to the easy (as well as some harder) fixes, lets take a look at how we got here. I promise I will eventually get to exactly how to use readily available technology, provide an I.T. roadmap, and point out specific EHR improvements that WILL dramatically improve the productivity in our health care system.
How did we get here? Well, until recently there hasn't been any real need to deal with productivity in our health care system.
Doctors, heretofore the real driving force in health care, were making plenty of money, and had few administrative and bureaucratic hassles besides the intrusion of the trial lawyers (and this was handled with defensive medicine paid for elsewhere—by insurance companies). There was not a lot of motivation to take a hard look at what it cost for doctors to provide care. They might quibble here and there, but really reforming business processes or deploying technology to take out waste was not a central focus. And we still hear the solution to financial shortcomings is “see more patients” or reduce administrative head count.
The insurance companies do not have much interest in productivity. They do not care about how much work effort a doctor puts into a diagnosis-treatment combination. They just pay an amount based on a schedule for the codes. If it takes a doctor 15 minutes, or a day, to generate the code they really don’t care.
Even government “insurance” puts up the illusion of reduced payments, the "Doc Fix". But again neither private insurance nor the government is concerned about the costs the health care provider incurs to get a fixed reimbursement. And, under sufficient financial stress, the private insurance companies can just raise rates and the government can tax or borrow more money.
The patient, of course, does not care one wit if the doctor is productive or not. They have no idea what it costs to provide care--after all, they rarely even know the prices. Contrast this to buying a car, where an entire industry has popped up to inform consumers of the “dealer invoice”. In health care the consumer doesn’t even look at the “sticker”. This is the natural way in any third-party payer system. And until very recently the patient did not even care about insurance premium rates that much--the boss covered it.
Unfortunately, instead of focusing on productivity and the important and obvious role of I.T. to drive it, we have spent billions of dollars implementing productivity-killing electronic health record applications. I have no beef with moving from paper to electronic, but it does not take a United Parcel Service efficiency expert (the best) to realize the technology we are deploying is not cost effective. Indeed vendor pitches for EHR systems emphasize government incentives. Rarely do EHR vendors tout productivity gains from the software, even the few that are actually concerned with productivity.
Compare that broad technology boondoggle with the experiences of a niche area of the health care industry--Lasik surgeries. The patient pays directly out of pocket, so they shop for quality and price. Ophthalmologists therefor have to compete on price. The lower price expands the market. The Lasik doctors naturally get very, very productive. Innovators come out with new technology to make the process safer and more efficient, and increase productivity of the Lasik industry. While the rest of health care cannot exactly adopt the Lasik's economic model hook, line and sinker, there are important lessons to learn.
The fact is few doctors, for good reasons, understand the role information technology could play to drive productivity. The management at hospitals and practices has no experience in other industries, most of which have gone through these stress points and had to drive productivity. And of course government does not even understand the concept of productivity.
This is changing. Doctors are overwhelmed with new government-mandated documentation; government medicine (direct and indirect) is becoming a larger part of the practice and the threat of reduced government payments is hitting home; costs for everything are going up; and some of us realize that the latest “technology,” the current crop of EHRs, are mostly designed by and for desk jockeys.
In the next post I will go through four obvious, to me at least, improvements to EHRs that can make major gains in the productivity of our health care system for the providers.