The Seven Myths of Healthcare Technology5. One Size Fits All

August is over, and so is, sadly, vacation. So, we came back to the office this week, to a pile of mail (I see that Canadian Tire had some nice sales in August) and a week of "start-up" appointments. One was a discussion with a partner company in Toronto. They are in marketing and were contacted by a potential client about an EMR/management system for small-office providers. As an SME, I was brought in to provide support. It sounded like a well-thought-out product serving a clear need. However, as we talked, I recognized a flaw in the initial assumptions;

Myth #5 "Solutions Are Shippable."

The potential client, a software vendor, was thinking of establishing a client base in Ontario and then expanding through Canada and the US--a reasonable and not uncommon business-development route for most products. Vendors and buyers of look on both sides of the border for new clients and better deals, respectively. This works with auto parts, fruit juice and so many other things--especially after NAFTA. And one would assume it would work with HIT as well--and be wrong.

Healthcare IT is only a device to enable a service process. It does not actually deliver healthcare. It just helps keep track of the healthcare being delivered. And that process is not the same everywhere. In Canada, the first goal of record keeping is accuracy of health data and surety of care. In the US, the first task is bookkeeping--determining payment liability and authority. In the US, there are HIPPA regulations carefully restricting access to patient information. These regulations are much more stringent and litigious than those in Canada, where a "circle of care" is more readily extended to include those brought into a patient's care process. These things change the nature of how electronic-record software should be not only managed and used, but actually structured.

In the US, software has be made to accommodate the tangled web of insurers and pre-authorizations required. Before care other than emergency stabilization can begin, financial responsibility and authorization have to be obtained from any one of a myriad of people and documented. Following that, HIPPA practices (coupled with litigation-risk management practices) require careful and full documentation of patient information and consent. Security functions (ID/password systems and access logging and monitoring) are required to assure HIPPA adherence by providers and facility staff. Then each service, each supply and each provider interaction has to be documented in a way that can later be billed successfully to whichever insurance company, HMO, employer fund or government plan may apply. This is often a complicated mix of incremental payments from a number. There often is still a significant balance to be charged the patient (or their family) which may require financing (and the related software functionality). Healthcare software must handle all of these requirements as core elements. This directs a large part of initial development to service coding, annotation of coding, coding-decision support and back-office interfaces and resources (billing office dataset displays and telecommunications with insurance company databases, for example). And these are core requirements for providers in the US.

In Canada, financial issues are far less complicated; a patient is either Canadian or not (or, in rare cases, not up to date on their Provincial premiums). This immediately clears authorization and billing for the majority of primary care services (more than 90% of all healthcare). For "non-urgent" care; optical and dental, elective services or "extras" like private rooms; billing is to one of the fewer-than-in-the-US insurance companies or to the patient. But the billing process is not a primary function in the electronic record. The "Circle of Care" allows easier involvement of providers and requires less documentation of patient information and consent. While patient privacy and security are highly valued in the Canadian practice, the limitations on provider liability in Canada reduce the urgency for liability-risk mitigation through documentation and security processes. Similarly, coding of diagnoses, treatments and prescriptions are important in the Canadian system, but for different reasons. While the US providers are working to ensure that they get paid, the Canadian providers are more concerned with helping organizations like CIHI in the development of trending data and national care standards (as examples).

Clerks in the US ask "Who's paying?" In Canada, they ask, "What's wrong?"

Software is a device to enable a process. While the goal may be the same everywhere, the process is not. And the software cannot.

Telling Grandma "No."

“...creating a national health insurance to cover everyone will probably increase costs, not decrease them, just as feeding the world's hungry three full meals a day would not reduce our grocery bill. Personally, I think instituting universal health care is the humane thing to do, but let's be honest: Somebody will have to pay for it.”
Dr. Tom Shragg, The Sacramento Bee, Sunday, July 5, 2009

Dr. Shragg describes himself as “a specialist in pulmonary and critical-care medicine with 30 years of experience.” In his opinion piece for the Sacramento Bee entitled “The Conversation: Is health care cost debate focused on wrong issues?” Dr. Shragg looks at some of the leading suggestions for healthcare reform in the US--EMRs, shifting of compensation from specialists to primary-care providers and a “single-payer” system---from his own view as an experienced special-care physician in private practice the US. His primary point is these solutions to rising healthcare costs are either inappropriate or plain wrong.
The doctor describes these foci of cost reduction as “the wrong birds.”
Dr. Shragg’s writing is reflective of his practical history. EMRs, he feels, are only a distraction from the healthcare process. Using and EMR, he writes, “slows me down and diverts my attention from the patient to the computer…These computer records may improve accounting, but not health care.” After 30 years in practice, Dr. Shragg (like most physicians) probably does little of his own charting, as nurses, PAs and other staff would be both taking and charting vitals, lab results, etc. He finds increased compensation for primary care over specialized care to be “naïve,” and “somewhat insulting.” As a specialist, he is understandably sensitive to the legitimate need for specialists. But as such, he has limited experience with the current US system’s “only pay for crises” incentive structure (it should be noted that the Doctor’s group practice does accept payment by most major insurance companies). And lastly, national health insurance might be “humane,” but it would not reduce the cost of health insurance (see above). All three are the “wrong birds.”
So, what does Dr. Shragg consider the “right bird?”
Dr. Shragg describes a 92-year old patient suffering a variety of late-stage ailments; renal failure, stroke and mild dementia among others. Her treatment included oxygen, consultation with a nephrology specialist, in-patient intensive care and dialysis. This is Dr. Shragg’s identified “bird.”
“If you wanted to eliminate the costs associated with that patient's treatment, you would have to empower somebody to deny the care she and her family desired. To borrow a popular expression, the elephant in the room that nobody addresses is the ‘R word:’ rationing.”
The US healthcare conversation is still ongoing, and no consensus has been reached, so it cannot be said if Dr. Shragg expresses the mainstream. But the Doctor’s does demonstrate something particular to US healthcare; commodification. Doctor Shragg’s access points to the issue are remuneration and funding--who is getting paid and who is paying them. In this dialectic, healthcare is a consumable--something to be bought and sold.
Every western nation currently has a national approach to healthcare, ranging from the single-payer/single provider (UK) to nationally regulated private-sector insurance with multiple providers (DE).
US focus on healthcare has only recently expanded beyond academia and industry, while many other nations are already at a “Phase 2” stage of revising a chosen healthcare architecture. In none of these nations is finance any longer a barrier to service. Citizens of the UK do not think about “health insurance.” They have “The National Health Service,” and like the Postal Service, it is expected and committed to deliver to everyone.
In none of these other nations is healthcare thought of as a commodity available only to those possessing adequate resources. They have already decided the question “who gets care?” with “Everyone.” Now they are working on the questions of access, of economies of scale and of quality of patient experience.
Canadian healthcare is one of the more mixed-bags of solutions. While healthcare is nationally defined as a basic right of all residents, its management is the responsibility of the Provinces; thus, there is Alberta Health Services, the Ontario Ministry of Health and the Ministry of Health of British Columbia, among others. Each Province has pursued its own solutions to healthcare. In Alberta, there is a single central authority (at present) that directly oversees each discrete facility. Ontario operates with a mix of state and private insurance, with regulated drug prices far below those in the states. The models in Canada, and the changes in these models are many and varied. As Canada successfully delivers on a national commitment to healthcare for all, the ways of managing delivery, access, quality of care, breadth of care and, yes, cost are always evolving.
This example of one nation successfully implementing a variety of solutions could serve as a valuable resource to the US in developing its own solutions. The US has a free-market hodgepodge of healthcare methods; state and local facilities and services; not-for-profit clinics; private practice and public-service doctors, and; insurances of all sorts. The successful mix of many Canadian models could quickly shorten the US learning curve. But to benefit from the Canadian example---or the French or the Swiss or the German--would still require a shift in US thinking. Other nations manage to deliver medicine and care to all of their people because they hold healthcare as a “must,” not a “maybe.”
Dr. Shragg writes of healthcare as something to be bought or “maybe” given as charity. His is not the only voice to lament the cost of late-stage care; but the US is the only nation to consider first and foremost the cost of care. If the US is to make a national effort (and to date the only national efforts have been the regulation of healthcare products--drug and device approval and patents and licensing), a true commitment by the nation must be made---to the nation.