We believe integrated will triumph fragmented every time.
-Steve Jobs
Two articles recently got my attention. The first was an interview by Dr. Robert Pearl, CEO of the Permanente Medical Group with my favorite author and thinker Malcolm Gladwell. On Pearl’s blog, he answered Gladwell’s request to tell people what is was like to be a doctor.
The second was a NPR article, “When Facts Are Scarce, ER Doctor Turns Detective To Decide On Care” by Dr. Leana Wen, patient advocate and author.
Both articles reminded me how doctors and patients have different realities simply by where they practice. As a practicing primary care doctor in an integrated health care system, which is partnered with a physician led medical group, these stories were quite foreign to me. These stories were once my reality in residency but no longer the case today.
The real question is will doctors and patients embrace the system I work in or continue with the status quo as outlined by Pearl and Wen?
In Pearl’s interview, Gladwell noted during a recent doctor visit:
… interacting with four support staff: three doing paperwork and only one assisting the physician with medical care. “That’s insane,” [Gladwell] said. ‘The only other industry in America that has a higher ratio of back-office to front-office is financial services, which also is a massively crazy business. It’s just wrong. It’s a misuse of resources.”
Gladwell continued:
“I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we’ve made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.”
Why are doctors crazy enough to accept this status quo? One of my colleagues is in a small group practice where she is the human resources person, the IT person, the chief negotiator with health insurance companies, and also the chief financial officer. On top of that she is also a sister, a spouse and a mother with other personal hobbies and interests. Of course, she still needs to be a doctor.
Aside from the byzantine and fragmented nature of the business of health care, there is another obstacle: the lack of patient information in a readily accessible format, real-time, 24/7. We still use paper charts and paper prescription pads. Unlike our smartphones, tablets, or computers which have much of our personal content of photos, emails, and songs on the cloud, health care has our information stuck in photo albums, letters, and CDs, locked up in someone’s home, attic, or who knows where.
Wen runs into this dilemma when examining a 73-year-old man brought into the emergency room by ambulance. The only information paramedics could provide was a name and address. The patient could only offer the year 1843 and two phone numbers that were not accurate. Wen, a resident physician, and medical student play detective.
The patient tells us his full name and says that the year is 1843. “It’s 2014,” I say, as my medical student looks for his records on a nearby computer. She shakes her head. He’s never been in our hospital. He gives us two phone numbers for his son, but neither works. The patient says his doctor lives in Kansas …
… He wants to go home. He pleads with us, saying he hates hospitals. He promises he’ll be ok. I try his home phone and his son’s numbers again. The resident calls two local hospitals on the chance they’ve seen him before. No luck.
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“The year is now 1914,” the patient declares. Everyone sighs. We have to admit him. It’s the last hospital bed we’ve got, and the patients who come after him will have to wait through the night in the ER …
The following day Wen gets a call from the patient’s son and daughter-in-law:
They’re irate. The patient has dementia and frequently falls. That’s why the family has arranged for live-in help 18 hours a day. The man has had anemia and kidney problems for years. His longtime doctor (here in town, not in Kansas) monitors these issues closely. The internist taking care of him say that the man never should have been hospitalized …
… When caring for patients we don’t know and who could have life-threatening illnesses, emergency physicians have to do what is safest and best with the information at hand, sparse as it may be. In this case, I made the choice to admit the patient. He was confused and had several abnormal test results. We couldn’t be sure he’d be safe at home.
As I listen to his family, I also see the other side. I can see how unhappy they are that he was stripped, poked and kept against his wishes. I understand their frustration at our system of sick care: Why don’t we have unified electronic medical records? Why aren’t there better interventions for coordinating care and keeping people out of hospitals?
I tell them that I’m sorry. Knowing what I know now, I would have made a different decision. I gently suggest that it would be helpful to make sure he carries a document in his wallet with updated phone numbers, medical conditions and wishes for his care.
Wen concludes her piece with another patient in the emergency room with a similar situation.
Would doctors and patients choose a different health care system if given the choice? Would they choose a system where care was streamlined and coordinated, information available 24/7/365, and doctors and patients could focus only on health by connecting, healing, and getting better?
Would they chose an integrated health care system partnered with a physician led medical group? In my reality, I have access to a common electronic medical record (EMR), which not only allows my colleagues and I to access a patient’s medical information in the outpatient and inpatient settings. We can collaborate on cases real-time. Patients also have access to their medical records electronically. Book appointments online, review labs results, refill medications, and securely email their doctors. We also now have access to other hospitals and health care systems, which share a similar EMR platform. Now I don’t need to repeat a CT scan of the head if a patient paid for one recently. I know exactly now which leg was scanned for a deep blood clot and when it was completed.
In other words, our system enables doctors and patients to worry less and focus more on providing better care.
With health care reform and the drive to make medical care more like any other consumer market with health insurance exchanges (think Expedia), transparency (think Amazon), and ratings (think Consumer Reports, US News and World Report), will a health care system I work in simply be seen as the same as everyone else as doctors and medical care become more like a commodity? Or will it be seen as something else — the future of American health care? Where I work, we are an outlier. We care for 1 percent of the US population. Will others join us and make a statement that they want something far better?
Time will tell.
Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.
