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Joe Boyd hated the Yankees.
\”Those damn Yankees. Why can\’t we beat \’em?\”
Then he got the opportunity to save his beloved Washington Senators by making a deal with the devil – giving up his soul in exchange for being transformed into \”Shoeless Joe\” to propel his team to win the World Series.
Interesting. I think a lot of doctors are making their deal with the devil. They are looking for a small gain in comparison to a long-term of misery. True, Joe Boyd made out in the end; but that will only happen if someone from Hollywood writes our script.
Here\’s the problem: at the core of our problems with healthcare is the total lack of cohesive communication. Doctors have no idea what other doctors have done with a patient. Tests get ordered, medications get changed, procedures, hospitalizations, even surgeries are done without communication to other doctors who would benefit from this information. The conduit of communication is this:
Doctor: \”So, how have you been doing over the past few months?\”
Patient: \”Didn\’t you get the notes from the hospital? I was in for two weeks. I had a heart attack and a stroke and now I am in rehab for both of these.\”
Doctor: (checks chart uncomfortably) \”No, I didn\’t hear about it. Why don\’t you tell me about it….\”
Situations like this happen daily at my office. Patients are started on medications by specialists without my knowledge. Lab tests are done that I have no access to. Huge changes happen in the lives of the patients for whom I have cared for over a decade, and I get nothing. Even consults I order are done without any communication back to me. On the other side of things, my patients are hospitalized without any consideration of the care I have been giving over the past decade. Patients are treated as if their care starts from scratch every time they enter a new venue.
It hurts my care for the patient. It hurts the other doctors\’ care for the patient. It hurts the patient.
And it costs a lot of money. Disorganized, we cannot beat this behemoth of dollars spent. Without good communication, communication that allows each person involved in the care of the patient to see exactly what is going on with the patient, the spending continues.
So what can be done about it? How can the care of the patient be organized? One common solution is the Integrated Delivery Network, or IDN. An IDN is a network of doctors linked together through a hospital. The care is integrated through a common record, or at least through a conduit that eases the flow of the patient from point of care to point of care. Academic medical institutions are IDN\’s as are many private hospitals (such as Kaiser – although Kaiser operates as its own insurance carrier as well). This seems to make sense. It breaks down barriers of communication and improves care.
But there\’s a catch: the hospital. Hospitals are often thought of as being on the same side as doctors – after all, doctors work for hospitals, right? While this is somewhat true for specialty physicians, many of whom make their revenue from procedures done on hospitalized patients, it is not true of primary care physicians. Hospitals are centers of care, yes, but they are also centers of spending. A hospital is not motivated to save patients money. Their profit is driven by patients being sick, getting tests and procedures done, and racking up cost. A patient can spend in a day in the hospital more than they will spend in a lifetime at my office. In this situation, the patient is treated as a commodity – something to use for a profit.
Does the hospital want me to be responsible, not ordering unnecessary tests, keeping patients healthy and out of the hospital? Do hospitals want me to get patients in hospice at the end of their lives, eliminating unnecessary hospital stays? Do hospitals want me to keep patients out of the ER? They won\’t get mad at me if I am the only one doing it, but all doctors getting responsible would be bad news for their bottom line. Selling myself with a hospital will put me in a conflicted position: wanting to please my employer, yet wanting to do what\’s best for the patient. In this way, IDN\’s are fatally flawed.
So what can be done? How can communication be fixed without letting the hub of the communication network be a source of spending? Think back to the conversation I recounted above. Who was the hub in that setting? The patient. Perhaps we should consider this model when moving toward a communication network. Perhaps a patient-centered communication model would optimize communication without raising cost. After all, shouldn\’t I answer to the patient – the one who is spending the money and the one who receives the care – for the decisions I make?
What if we set up a decentralized communication network that was linked not by doctors, hospitals, or insurance companies, but by permissions given by a patient? Here\’s what I mean:
- I would have access to any records on the patient on any clinical database that the patient allowed me access to. Instead of importing labs into my system, I would have access to the laboratory\’s system for any patient I had permission from. That way if the patient had labs done by another clinician, I could see the results. If the patient was at the hospital, I would have access to those records as well.
- I would give access to any clinician who was given permission by the patient to see my records. If the patient was in the emergency room or in the hospital, the doctors there could see what I have been doing with the patient in the outpatient setting. If a consultant wondered why I ordered a consult they would have easy access to my documentation of this.
Sounds risky? I think it is less risky than a centralized database with all the information in one location. Sounds hard? Isn\’t what I described just a description of what the internet is? Information on my blog is not downloaded on your computer, you just have access to it. If I wanted to deny access, I could. If I wanted to limit that access, I could do that as well.
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This is exactly what happens with banks as well. The consumer has control over access to bank accounts. If they want to allow their gas company to draft from their checking account every month, they can. They are not required to gather all of the banking information in one location, it is spread out among many.
In baseball, often it is the team who spends the most money who wins in the end. Those of us who grew up hating the Yankees can attest to that ugly fact. Healthcare is presently run by those who control the money: the insurance companies and the drug companies. They win because we can\’t afford to fight them. They win because the minute they get behind, they find a way to use their money to get back on top. But we don\’t beat such spending by selling ourselves to fix our short-term problems.
To fix this problem, we don\’t need more of the same. We need the whole way the system is set-up to change. We need the rules to change. We need a change in ownership.
Dare we admit that the real answer to our problems is in the hands of our Washington Senators?
You have obviously thought about this quite a bit. So, how do we get the special interests to think about this as much as you have? The insurance industry has to like saving money. The part of the hospital that has to pay for ER visits in lieu of insurance has to like it.
As an aside, has anyone (besides them) studied how much Kaiser’s system saves them and how well it impacts the quality of care?
Choke …choke…hate the Yankees!?! I’ll just have to let that one go for now. Sigh.
This is a great model, Dr. Rob. The fatal flaws are ones you already identified: patients, doctors, insurance companies and drug companies. Patients can be dunderheads, doctors can be irresponsible and greed is the bottom line for the last two. An education program directed at patients and doctors could help it succeed. But unfortunately some people are awfully slow learners.
It’s not that I hate the Yankees…it’s just that I like every other team a WHOLE LOT more. Regarding the patients being the sticking point, the system is already so dysfunctional that the worst-case is that we stay where we are in reference to communication. This would most improve the care of patients who are the most involved, which I think is fair.
I bet this isn’t quite what you have in mind, but I’ll tell you, it works well. Honest. Here in Xalapa, in the state of Veracruz in Mexico, we have an internist who is very definitely our primary provider. He actually examines us extensively (his appointments are set for a half hour to an hour. He refers us for tests and to specialists. When we get tests, they are delivered to us, not the doctor, but addressed to the primary. Same for consults with cardiologists, et.al. Their findings are addressed to our primary, but we pick them up. If we have a problem serious enough to lead to hospitalization, the primary is always contacted. He attends us in the hospital along with specialists. We get our records from the hospital, too. We go to the primary for an appointment called a review of results. We bring all the stuff. The doctor opens it and reads it while we sit there. He discusses the results with us, integrating them with the rest of his knowledge of our health. He writes down (or enters in a computer) the significant information and hands us back the originals. We keep all the originals, hopefully filed in an orderly fashion. Should we change doctors, we have all the stuff, an the primary also as a compete record.
I know it sounds ummm medieval, but it really, really, really wors.
I would have access to any records on the patient on any clinical database that the patient allowed me access to.I would give access to any clinician who was given permission by the patient to see my records.
I am in agreement as long as it is with Patient permission and that permission should be applied for every time and not that a patient signs and then there is a free for all for everyone.
I would think it would be just like access to medical records is now. Some would have one-time access (such as an ER physician), while others (such as a PCP) would have access as long as you continued allowing it. As a PCP it would not be good to have to ask every time I was accessing information on a patient. I think any specialist the patient saw regularly would probably be allowed ongoing access as well.
It does sound amazing. It sounds like a satisfying existence for the PCP, as he is doing what we are all striving for: being the hub of medical care – the medical home.
Interesting post, with lots to chew on. This is what I don’t understand about ACOs, which seem to be the flavor of the month in health reform. What in the world is going to induce our mega-coporate hospital complexes to rack up fewer charges? Seems like the PCPs will be eaten alive in this scenario.
And isn’t a large part of the problem with communication the fact that “partialists” really have minimal interest in what other docs do with their patients? They’re just taking care of their one area of responsibility. If we really want generalists to manage the whole patient and do real “coordination of care,” somebody’s going to have to pay us to do it. The time and labor involved can’t be given away for free any more.
What an excellent idea! As long as it’s secure, I’m all for it.
I have a seriously ill relative – I solve the problem by carting around a binder of tests and CDs of scans etc. everywhere. And keeping a detailed medical history, and log of events. It’s a pain, and takes a lot of organization. Most people aren’t going to manage that, especially if they’re elderly/seriously ill.
None of this solves the problem of different docs only treating “their piece” of the patient, and prescribing drugs that clash. Yes, they’re supposed to notice. Yes, the pharmacy is supposed to notice. No, they don’t always.
Here’s a revolutionary idea… why don’t we have encounter information read from a smartcard that the consumer/customer/patient carries?
The good news: It’s feasible, simple and doable – and it keeps patient info where it belongs – in the hands of the patient.
The bad news: Being in the hands of the patient, it is bound to get lost.
Nice work. The question is, are our legislators less corrupted by $$$ than hospitals and insurance companies, and even (gasp) physicians ? I doubt it. Will and Ariel Durant, who wrote 12, or is it 13, huge volumes of world history together, asked rhetorically about China: What caused this advanced civilization, inventors of paper, gunpowder among many other marvels, to devolve into a series of warring fiefdoms? (my words not theirs); their answer: Bureaucracy. The overburden of regs and laws and the corruption that is associated with them has been piling up geometrically during my own little lifetime. The North American flowering of liberty and discovery will be, must be, re invented by other cultures. Fortunately for humanity, that is what happens, and they are already starting to do so.
As to young physicians here in the US today, we will be OK. It is only the culture that will be lost, and maybe that is not a bad thing, all considered. We will still be among those most capable, ambitious, and resourceful in our society. Nothing will change that unless we lose our minds. It’s our choice to adapt or emigrate, but if we want to, we will still be find if we keep our heads.
jl
I am very much in favor of the system you propose! Having taken care of seriously ill relatives who were treated by more than one doctor (and had tests in more than one hospital), I’m very aware of the problem. I ended up having to control into my own hands, but that doesn’t always work…
With my FIL, I was able to get cooperation from almost all everyone except the hospital. They would do tests and then refuse to fax the results to George’s doctors. I would have to call the doctor for the results, they could have to call the hospital, *then* the hospital would send the fax. These were not unusual tests, these were frequently the same tests being performed EVERY WEEK on a standing order. For his doctor visits (an internist who was the primary care, a cardiologist, a nephrologist and sometimes others), after every visit or phone call or med change, I typed up the results and faxed them to all the doctors myself. George’s file was a foot thick at each office, but everyone knew what was going on… which hadn’t been the case a year before, when I wasn’t taking care of him and four different doctors prescribed four different blood thinners, the hospital pharmacy didn’t catch it and he almost died.
With my mother, the doctor’s wouldn’t work with me. I was told that the test results wouldn’t make sense to me, that I didn’t need to know these things. Because they were my mother’s files, and she didn’t insist that they share the results with me or send them to the other doctors, nothing happened. You’ve got to have the patient motivated to be involved…
Great post! I think patients can be educated! Why not start when patients are adolescents, expressing the importance of their keeping track? Parents could provide them with a special folder, docs (or hospital….they certainly print enough!) could provide a label.
For myself, every visit, test, etc., I have, I ask for the records. Then I make copies for my physician(s), so everyone is on the same page. I also have a personal information sheet when I have been told by docs and their employees, is very welcome. (In Nevada, which is a “Right to Know” state, where patients have access to their lab reports directly from the lab, thus cutting out a lot of hassle and doctor expense, getting those reports from the ordering docs. This also makes a lot of sense to me.) Recently I had an X-ray, took a copy of the disk when I left, got the report later.
Seems like information control is loosening up. I have not had a problem getting info from a hospital for a long time. Indeed, it seems like they are making Medical Records ever more accessible. Now, when I have blood work, I ask them to send the report to my other doctors. I just have to sign a permission/request form. (They don’t always send it, but it’s a start….)
Philosophically: I wonder if folks do not think they are important enough to take good care of themselves and to follow their own health care? So perhaps we need practice to value ourselves and each other culturally? I see a lot of “throw away” attitudes in this culture……maybe the devaluation of personal medical information is a symptom of this?