We've Always Done It That Way

A loved one of mine recently had to spend a few days in the hospital.  Now, the procedure went well, she’s home and recovering fine, and the staff at the hospital – from the surgeon to the people cleaning the rooms – were uniformly cheerful, helpful, and friendly.  Still, I came away from the hospital experience thinking – really, this is best we can do?

The following are some of my pet peeves about hospitals, particularly things where the patients don’t seem to be coming first.  In no particular order:

• Hospital Gowns: Let’s start with that familiar piece of appeal that is ubiquitous not just in hospitals but throughout the health care system -- the backless hospital gown.  If an evil genius wanted to design something to take away a patient’s dignity, they wouldn’t have to stray too far from the standard gown design.  They don’t have to be this unflattering.  For example, the Henry Ford Innovation Center has introduced a gown that is in use at Henry Ford Hospital that acts more like a wraparound bathrobe and is much more popular with patients.  The question is, why aren’t more hospitals (and providers’ offices) following suit?
• Semi-private rooms: Aside from a few (dubious) claims to the advantages of companionship offered by having a roommate, there is widespread and longstanding consensus that private rooms are the way to go.  Lower chance of infection, better sleep, and increased patient privacy are commonly cited advantages of private rooms.  As hospitals renovate or build new wings, they tend to feature private rooms.  But that still leaves an awful lot of semi-private rooms in our health system (I’ve yet to come up with a count but I suspect it is the vast majority).  Even worse, if a patient requests a private room when there are semi-private ones available, the patient usually has to pay the difference – at charges.  That’s crazy.  Hospitals should be offering steep discounts when patients have to use semi-private rooms.  That would speed the conversion.
• Patient monitoring: Why is it that patients get woken up several times a night so that staff can take their vitals?  It’s bad for sleep, which is bad for patients, and probably impacts the validity of whatever measurements are being taken.  Maybe hospitals haven’t noticed, but remote monitoring options have proliferated in recent years.  I’m sure that there are some patients who do need to be checked in person, but I severely doubt it is all patients, or that the checking always requires the patient to be woken.  Let those people sleep!
• Uncertainty:  A patient’s life in the hospital involves a lot of waiting around in bed for something to happen – a visit from a physician, a blood draw, a CT, etc.  The patient rarely knows when any of these is going to happen, aside from perhaps a vague time frame.  We get it: the staff in hospitals are busy, and unpredictable emergencies happen that can throw schedules out of whack.  Nonetheless, patients deserve better.  If hospitals were run like a modern manufacturing plant, with real-time inventories and tracking, they’d know where everyone was at all times, when schedules are falling behind, and how to adjust accordingly, so patients could be kept in the loop.  Maybe Toyota or Amazon should run hospitals. 
• Patient tracking: As soon as my loved one registered (a task, by the way, that could only be partially completed in the online pre-registration process), she was issued a patient ID wristband.  Each time someone did or gave something to her they first made sure they scanned the barcode on the band.  I appreciated their effort to ensure they were dealing with the right patient, but I always felt it treated her like a piece of merchandise.  These are hospitals, dealing with live people – ever hear of biometric identifications?  Again, this technology is out there; it’d be nice for patients to be made to feel they are a person in a hospital instead of a slab of beef in Kroger.
• Patient entertainment options: while patients are doing all that waiting around, it’s often hard to keep entertained.  Admittedly, having a TV for each patient is pretty standard, and many hospitals also now offer WiFi (although not always secure WiFi), but I have yet to see a hospital TV that doesn’t use the old-fashioned tethered remote that only allows patients to navigate stations one-by-one.  Since soon hospitals will be giving patients access to their electronic records (ahem, Meaningful Use Stage 2, anyone?), they might as well go to options that feature full internet access, video-on-demand, streaming, and other modern entertainment features.  This is not pie-in-the-sky stuff; the technology is out there – e.g., GetWellNetwork or Skylight Healthcare Systems – so why isn’t it used more?  BYOD should certainly be allowed but shouldn’t be the hospitals’ strategy.
• Not So Electronic After All: The room my loved one was in had a screen and keyboard attached to the wall (although not at an angle some of the nurses could easily access, mind you, and definitely not available for patient access), but I noticed that not every one of the staff used it to access her records.  Some brought in another computer, while a disturbing number carried paper records, which they either read from or wrote on.  I was disappointed, but not surprised, to see that no one was carrying a tablet.  I’ve written on this before, but the experience really highlighted how simply having EHRs doesn’t mean they are used to best effect.  I suspect that the UPS driver who delivers to my house has a more well-thought out system for accessing and updating information real-time than the health care professionals in most hospitals do for viewing and updating patient information.
• Too big: Many hospitals have grown organically over the years, often resulting in huge complexes that lack a central plan.  Patients and their families have other things on their minds when they are there, and the complicated layout and medical terminology used add to their anxiety by making it hard to navigate.  Some hospitals are advocating a process design approach called “wayfinding,” borrowed from shopping malls and airports, that is intended to help people navigate.  In a perfect world, hospitals would be designed from scratch with patient navigation in mind, but wayfinding at least tries to make some sort of recognizable purse out of this particular kind of sow’s ear.   Personally, I think the real problem is that many hospitals have simply grown too big and wish we could start over.
• What Happens Next?: One of the professionals treating my loved one confidently told her what to expect over the next couple of weeks, and I kept thinking: how would they know?  Face it, neither the physicians in the hospital, nor even the physicians in the community, really track patients once they leave the hospital.  They might get phone calls or do follow-up visits, but actually knowing how patients are faring day-to-day or even week-by-week is not typical.  It’s being done already, so – why isn’t it being done more? 

I don’t mean to pick on any particular hospital, and I suspect – in fact, I hope -- that for every example I listed there are counterexamples.  Nonetheless, I worry that they’re more common experiences than uncommon.  I’d be interested in hearing about other people’s pet peeves about hospitals – and I’d especially love to hear about counter-examples where a hospital has done better for patients.

Hospitals have a lot of caring, smart people working in them, all of whom presumably want what’s best for the patient.  I sure hope the barriers to addressing them are more than “we’ve always done it that way...”

20th Century Health Plans in a 21st Century

It’s almost kind of shocking to realize that we’re fourteen years into the new Millennium; doesn’t Y2K seem like a long time ago?   On the face of it, it would seem that health plans have never had so much change thrown at them as they have in just this decade of the new Millennium – mostly but not entirely due to ACA -- yet sometimes I worry that the changes they are going through are more like trying to put jet engines on a biplane instead of taking the time to truly redesign the plane.  It might work, but chances are it’s going to crash. 

It’s high time we rethink what health plans are and what they do.  I’ll give an example later on.

Let’s face it, health plans are not often known for speedy processes or use of the latest technology.  A recent report by HealthEdge (which, it must be said, has a vested interest in the topic) highlighted the continued use of “antiquated legacy technology.”  The health plans surveyed overwhelmingly saw the need to automated manual processes (81%) and increase auto-adjudication rates (56%).  It’s easy to look down on CMS for what happened with healthcare.gov, but if anyone was to probe very deeply into health plans’ technology, I suspect they’d have more than their fair share of embarrassing examples as well.

Health plans are trying hard to change.  They absorbed the requirements to cover dependent children, have started to live with the new medical loss ratio (MLR) standards, have revamped their benefit designs to fit the ACA standards (which, of course, resulted in the wave of cancellations that hurt ACA almost as much as the healthcare.gov debacle), and have totally changed their rating and underwriting processes in the individual market.  Those are huge changes, but are only the beginning.

The exchanges and the individual mandate have woken insurers up to the realization that health insurance is going to be retail in a way we have never seen before.  Aetna CEO Mark Bertolini predicts all this will cause health insurers to spend billions on consumer marketing (which, of course, will impact those MLRs).  Many health plans saw that future well before ACA.  Florida Blue opened its first retail store in 2006, and not only have they subsequently added more stores but numerous other health plans have followed suit – e.g., Highmark, Kaiser and United Healthcare.  Aetna has its own retail approach, partnering with retail chains like Best Buy and Costco.

The payor consumer strategy is not only bricks but also clicks -- Chilmark Research just released their Payer Benchmark Report 2013, and one of their key findings was how health plans’ use of consumer tech to engagement with members has exploded.  A PWC report reached the same conclusion, noting that health plans especially need mobile options to win the highly desired “young invincibles.”

Despite the health plans’ efforts, consumers’ opinion of health insurance companies remains largely negative – a Kaiser Foundation poll found only 43% had a favorable opinion (and, frankly, I’m surprised it was that high).  Worse yet, consumers with more recent experience with a health plan only had 35% with a favorable opinion.  Health plans seem to shoot themselves in the foot when it comes to dealing with consumers.

I think they’re doing it again by the explosion of narrow networks in the exchanges.  The idea, of course, is that health plans can offer lower premiums by limiting their networks to lower cost providers, assuming (correctly) that consumers are highly price sensitive when looking at premiums.  It also may be a not-so-subtle way of getting around the guaranteed issue requirements; consumers with more complex health problems may be more likely to be associated with higher cost providers, such as academic medical centers, and the exclusion of such providers from the narrow networks may well keep those sicker patients from enrolling in plans utilizing them.  

It’s a double win for the health plans – able to offer lower premiums due to including only lower cost providers and by attracting lower cost patients – but one that may prove short term.  I think it’s a short term strategy, because neither providers nor patients are stupid. 

Health plans tried narrow networks, and tight utilization management techniques, in the early 1990s, and they were successful in reducing cost increases, but a combination of provider consolidation and consumer backlash forced them to back off.  How long until the same happens in the exchanges?

I think we should move past the concept of networks entirely, and that’s an example of how I would revamp health plans.  Instead of managing a network – deciding which providers are in and out, negotiating reimbursement contracts with each of them, etc. – why couldn’t the health plan act as a “provider broker” for consumers? 

In this approach, the health plan’s role is to help consumers find the right provider for them, based on cost, quality and other consumer preferences, rather than to select the set of providers consumers need to pick from.  And I don’t mean giving them, say, a selection of ACOs or other integrated delivery service and then locking consumers in to one of them in for all services.  I mean, given a specific health need, helping the consumer get to the right provider(s) for that need.  Just because an ACO is best at caring for diabetics doesn’t mean anyone should also get their heart transplant there.

All of a sudden the health plan would go from being seen as limiting choice to being seen as enabling choice.

Current transparency efforts by payors or the many vendors that have popped up in this space really only help consumers find providers within the network of the health plan they are already enrolled in, which is very different than helping them find the “best” provider anywhere.

To facilitate comparisons, the costs would have to be all-inclusive, bundled rates for specified sets of services.  Providers would probably have to bid on their rates (which may not vary by payor), and coordinate between the various required providers.  To avoid the local monopoly problem, available options should include providers in other areas, especially for high-risk, non-emergency types of care. 

In this role, if the health plan still has financial responsibility – and I do not take that as a given that they would – I expect they would have to use a reference pricing approach, so that consumers could choose whatever provider they wanted but would be liable for any amounts providers charged over the reference price.  That will make both providers and consumers price sensitive very quickly.

Health plans sell an extremely complicated product that consumers don’t understand, don’t like, and think is too expensive.  Providers also see them as administratively burdensome and with a penchant for interfering with care delivery.  So who is it that wants to keep health plans structured as they are?  Surely in 2014 we can do better.  Let’s stop tweaking an outdated structure and rethink the entire approach.

They Shoot EHRs, Don't They?

For all of us who have been waiting for EHRs to revolutionize health care, well, I fear we may have to wait a while longer.  Many a lot longer.

That may sound odd, because there would appear to be lots of good news on EHR adoption.  Karen DeSalvo, the National Coordinator for HIT at HHS, thinks so.  She reports that nearly 80% of office-based physicians use some type of EHR, almost 70% of office-based physicians intend to participate in the federal EHR incentive program, and 48% use a system that qualifies as at least a “basic system.”   Indeed, CMS reports over $16b in EHR incentive payments – to 386,000 professionals and 9,400 hospitals. 

That’s all good news, right?  Not so fast: witness an article in The New York Times on the growing use of “scribes” to do the actual input into the EHR for the physicians – often being right in the exam room with the physician.  The article cites several sources who see the input as purely clerical.  “Making physicians into secretaries is not a winning proposition,” says one primary care physician in explaining the problem.  The cost for these scribes is typically borne by the practice, and is made up by improving the physicians’ efficiency in seeing more patients.

Somehow I can’t help but feel we’ve taken a wrong turn somewhere on the road to EHRs.

CMS has spent $16b to incent EHR adoption, hospitals and providers have spent some multiple of that amount to buy and install the EHRs, and yet practice overhead – and probably health care spending -- is going up in order to pay for scribes to actually use them?  No, that’s not good news.

It’s worse than that.  A report released last fall from RAND and the AMA found that the current state of EHR technology has significantly worsened physician dissatisfaction in multiple ways, including poor usability, data entry, impact on face-to-face interface with patients, and conflict with clinical workflow.  Physicians like the concept in principle – just not in actual execution.

ONC knows usability is an issue, and claims it is a priority.  They note that barriers include that fact that the buyers often aren’t the actual users, that it’s hard to change EHRs once implemented, and that they exist in the context of legacy software that is hard to change.   All are valid barriers, and none are ones that are likely to change in the near future.

One would like to imagine that all the EHRs that have been put into place reflect thoughtful analysis of the costs and benefits from the hospitals and physician practices, but that may not be the case.  The IOM just released a proposed standard model for evaluating ROI on EHRs, which seems like a good idea…five or ten years ago, before all those billions had been spent.  One wonders what kind of analytical models have been used in the meantime; I hope the purchase decisions weren’t simply due to the desire to not miss out on HITECH incentives.  

Even worse, another recent report from RAND did a meta-analysis of studies involving health IT, and found less-than-robust results.  As the authors say, “[A]lthough the health IT evaluation literature base is expanding rapidly, we are concerned that there has not been a commensurate increase in our understanding of the effect of health IT or how it can be used to improve health and health care.”  They conclude, “the health IT literature is expanding rapidly but failing to produce a commensurate amount of useful knowledge.”  We’re not only not producing useful knowledge but we’re also not even quite sure how we should be studying the impacts of HIT.  

We may be in the era of “big data” in health care, but we’re not be in the era of useful data yet.

Adding insult to injury, a report from IDC Health Insights found that 38% of documents used in health care are still paper (and I find that way, way too low), a third of which just get typed into a computer at some point.  And, according to IDC, 62% of health care workers say volume of paper has increased or stayed the same over the past few years, despite the huge increases in EHR adoption.  Those findings illustrate that EHRs are simply adding work, not replacing it or making processes more efficient.

Hard as it is to believe, the increased physician dissatisfaction, lack of evidence of improved outcomes, and questionable ROI are not the only bad news.  OIG released a report earlier this year that warned that CMS has not done enough to deter fraud and abuse associated with EHRs, such as the use of “cut-and-paste” functions that may help providers document care that was not actually provided.  OIG warns such practices may have led to $75b to $250b in healthcare fraud.  That’s serious money.

So, yes, overall it’s hard to see that we’re getting the desired bang for our EHR buck.

I am deeply sympathetic to physicians, but -- unless they also had scribes for their paper records (or dictated notes for transcriptionists) – that sympathy has its limits.  Moving to EHRs undoubtedly requires significant changes to clinical processes in order to be fully effective.  I worry that physicians who employ workarounds such as scribes may not have truly evaluated what changes the EHR means for their practice.  Reengineering work processes is one of the hardest things for any business to do, but if any industry needs it – EHRs or no EHRs – it is health care.

Nor am I buying the argument that physicians are computer or technology phobic; a study last year from Epocrates found 86% of physicians use smartphones in their professional activities, and 53% use tablet at work.  Not exactly a bunch of Luddites.  I blame the design of EHRs.

A well-designed EHR shouldn’t be harder than paper records to keep, view, or add to, while they should provide much, much better ability to detect trends, receive real-time warnings or suggestions, and move data from one provider to another.  It should fit into and improve clinical workflows.  So why don’t we have such well-designed EHRs?

I wonder if HITECH has had the effect of impeding progress.  Lots of smart people have done lots of hard work in coming up with the federal certification process and meaningful use standards, but federal standards are not usually associated with innovation.  In fact, what other industry (besides education, which is its own sad story) needs federal incentives to computerize its processes and go digital?  Our big investment in EHRs is well on its way to being used to raise costs and decrease efficiency.  You have to admire the U.S. health care system for its chutzpah. 

I don’t normally drink the Apple Kool-aid, but when it comes to EHRs I’m wondering where the Apple-like products are, ones that surprise and delight their users.  Apple didn’t need federal funding to develop the iPod, iPhone, or iPad, nor did their users ask for incentives to buy them or to change the way they access music, movies, or a host of other parts of their lives.  Nor do those users typically hire other people to hit the keys for them.   

What I don’t think we’ve really done is fundamentally rethink the concept of a patient record.  We shouldn’t be simply putting the paper record in an electronic format; we should be creating a 21^st century version of it – interactive, visual, collaborative.  It should be part of the clinical process – not an impediment to it -- and should serve as an added diagnostic tool.  Its use should delight clinicians and make their jobs easier, not force them to hire scribes to use them on their behalf.

If any organization is doing that, I’d like to know about it.