The Problem with Healthcare

First, two comic takes on the Cheney shotgun incident (by the way, can you believe Whittington apoligizing to Cheney and his family for being shot?):
- Cheney's motto: The buck(shot) stops here
- Fans of popular music a decade or so ago will appreciate thus: "Cheney's got a gun..."

And now back to our normally schedule blog. I've been spending the last week or so immersed in healthcare technologies. Specifically, these are what you might call the "back office" capabilities required for a doctor's office in private practice, or a group practice, a hospital, etc. Some of the technology is "middle office" - scheduling, calendaring, some diagnosis, etc. In short, there's a HUGE market out there of companies selling (or trying to sell) technology to the healthcare field...and this doesn't even take into account the technology used by pharmaceutical companies for R&D, marketing, etc.

The majority of the enthusiasm and unbridled capitalism in healthcare has been driven by a couple of initiatives: HIPAA, which basically wants your health information to be "portable" (the "P" in HIPAA) so that no matter where you might want to be treated, your information would be happily made available to the practitioner(s) you select. Of course, your information must also be secure, sealed away so tight that you yourself can barely understand it or grab it when you need it.

The other intitiative is also valiant effort by the Bush administration (currently) to playfully suggest that a nationwide network of interconnected healthcare providers (doctors, hospitals, dentists, psychologists, etc.), payers (insurance companies, HMOs, etc.), and patients (that's YOU) can all easily trade information around the horn, as it were, to ensure prompt and accurate care, service, and payment. This directive has been mandated and has begun to take shape in various forms, including critters called RHIOs (regional health information organizations) that will purport to do the nationwide job described above on a smaller regional scale.

Yeah, right. And Vice President Cheney will soon be joining the Olympic biathlon team.

There are a few problems with this. First and foremost is the level of technology adoption at most provider sites (if not payers, which move at a glacial pace but have gotten more high tech over the years). Providers are CHEAP. Like lawyers, they hate to spend their money on dopey stuff like computers and software. This is why you continue to see racks and shelves and rooms full of paper file folders in your neighborhood doctor's office. And face it - depsite the TONS of products and technologies out there, with more acronyms and specialty terminology than the armed forces could ever dream of (EMR, EHR, PMS [not that one], EDI, HL7, CPT, CCR, PHR, coding, revenue cycle management, transcription, code sets, etc.), when was the last time you saw ANY doctor you met with use technology to do ANYTHING short of viewing an X-ray (that's PACS technology, btw) or taking an ultrasound? Who's using this stuff? Has any doctor you've met with whipped out his ruggedized tablet computer and speedily entered your diagnosis, retrieved a course of treatment that agreed with his diagnosis, noted your allergy to a certain drug, and zapped the information to your insurance company? I think not.

The problem is one of expectation. You and I EXPECT the healthcare universe to be focused on - guess what - HEALTHCARE. Caring for the health of the patient. Making you better when you are sick or injured. However, it turns out that the vast majority of technology in healthcare - in the healthcare informatics space, as it's called - is focused on - guess what - PAYMENT. "Revenue cycle management", one of the hottest tech spaces in healthcare, is a euphemism for "make sure we get paid". Doctors spend a bunch of time in med school learning how to "code" - not as in code blue, as we all have seen in ER - but code as in make sure that they know what codes are entered for what they (1) diagnose and (2) treat (different codes, by the way) so that (3) they get paid quickly and accurately. And as more entities come between you, your doctor, and your wallet, guess what? It gets harder for the doctor to get paid. Surprisingly, the growth of HMOs, PPOs, etc. has made it harder, not easier, for doctors to be reimbursed; it's obviously easier for you to give the doctor cash or a check on treatment and he takes it to the bank, but the wonders of insurance that promise to reimburse you sort of gum up the works. The result? Bills that can barely be understood by smart people with 12+ years of post graduate schooling.

It is quite eye-opening that almost the entire emphasis of healthcare informatics - from practice management, to coding, to the electronic medical record (worth another few pages of type), to revenue collection, etc. - is advertised as a way to "optimize the revenue flow to the provider" and "capture all the payments to which the provider is entitled". You'd expect something more like "deliver swift, accurate care to the patient" or "reduce the possibility of errors in treatment", but those must be less noble goals.

I don't argue with providers being paid. But let's call a spade a spade and not fool ourselves that a nationally interconnected network of healthcare stuff will (1) work soon or (2) be focused on the needs of the patient, at least not at first. Indeed, the national health network is typically discussed in terms more relevant to homeland security than health and welfare (though staving off epidemics and pandemics seem to be at the heart of the directive as well). Even the concept of the RHIO noted above faces a significant stumbling block - who will pay for it? Articles about "best practices" invariably contain the mantra of "start small" and "organize appropriately to identify responsibility" and "figure out who's paying the check." I'm a technologist, and from a technology perspective, I think we can get there, but like many other ventures, this isn't so much about technology as it is about finance and priority. Until those fall in line and until our governments organize for this more effectively, the notion of interconnectivity, interoperability, and "easy to use" healthcare won't happen soon.