Random Thoughts from a Restless Mind

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something this small and seemingly insignificant unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this! The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor — patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor — patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system, and all before the 3rd party payer.

For whatever it’s worth I’m 5’8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.

Consider this an official “Request For Proposals” from Arnold Kling to design a health care plan. And just so Dr. Kling doesn’t think I’m picking on him, what the heck, let’s hear from Tyler Cowan and René Herszinger, to0. While I’m at it, I have a certain health care policy rock star brother-in-law, Jim, and I’d love to hear what he has to say about it. Let’s toss in that blogger Maggie Whatever-Her-Name-Is, and why not invite one of the smartest guys I’ve ever actually chatted with, guy named Barry Cooper in Louisville. I’m ready to appoint each and every one of you, and anyone else who’d like to take a shot, as uncontested Health Czar for a large group of people. This is a Request For Proposals to design a health care plan from scratch.

Let’s see who’s got game.

This isn’t something I just made up; this is actually a real group and a real possibility, although it’s highly unlikely that the real players have either the imagination or the balls to really do something new. Nonetheless, it’s very cool to apply imagination and balls to this question. The group consists of 250,000 individuals, 95% men, between the ages of 20 and 60. The average age is 45. Once they become part of this group they essentially remain so for their entire working career. They have a single labor representation, and while they work for a number of different companies there are four major employers. Health insurance has been part of their negotiated contracts for decades.

You have carte blanche to design a health care program for this group. You are not bound by any ERISA regulations, and you will “participate” in any financial savings you might create. Let’s say that it will be a 10 year trial, and in year one you have the average amount of money actually spent on healthcare over the past three years for this group. Each year the funds available to you will increase by only the CPI, inflation in the general economy and no more.  In years one through five any money that you do not spend is yours to keep. Remember, the members of this group do not come in and out, and any investments you make in the early years that reap savings in latter years will come to you and not another provider or payer. In years five through 10 you will share any savings with the employers, the payers.

As part of this proposal you must not only try to save money, to provide health care in a more cost–and efficient manner, but you must also achieve superior health. In years one and two the health outcomes of your 250,000 members must be no worse then the aggregate outcomes across the United States for individuals in a similar demographic. However, in years three through 10 you must demonstrate superior health outcomes for your group, each year better than the last. In other words, you must design a program that will not only save money but will also produce superior health.

That’s it. No other rules. You may use economic incentives with the members, both positive and negative. You may put together what ever type of provider group, physicians and physician extenders, hospitals and clinics that you wish. Pay the healthcare providers any way you’d like (probably ought to be sharing the lion’s share of any savings with this group, if you wish to be successful). You only have to do two, simple things: make these 250,000 men healthier, and spend less money doing so.

Wadda ya think, Dr. Kling? You in?

I don’t want to sound like I’m picking on Dr. Kling because it was actually his short manuscript, “A Crisis of Abuncance” that really got me to thinking about the barriers we have erected in our healthcare system to actually providing healthcare, providing for the creation of health. The best example of what you CAN do, as well as what happens now when you DO do, is the Mayo Clinic program designed to take care of patients with kidney failure. Given free reign to design a program that would accomplish exactly what I am asking for with my 250,000 member group, the Mayo Clinic did just that. By creating a team that was given free reign to utilize best practices, the Mayo Clinic designed a program for kidney care that resulted in fewer mortalities, fewer complications, and greater health, all with a lower price tag.

So why, you might ask, do we not know more about this program? Why is this not the gold standard for ALL medical care, let alone chronic kidney disease care in the United States? The sorry fact is that the Mayo Clinic actually LOST money on this program despite the fact that their patients had BETTER health by doing less and doing it better, thereby resulting in the need for LESS work still, The Mayo Clinic essentially cut off its nose to spite its face. Not willing (and reasonably so) to lose money, and unwilling to practice medicine any way less than what they have shown to be best practices, the Mayo Clinic has now declined to care for Medicare patients in some of its satellite locations.

But you guys don’t have to worry about that. I’ll let you keep the cash! So, what do you say, folks? Ask your friends. Everyone can play. We might even catch the attention of the real, live people who are presently negotiating new labor contracts for this very group. Here’s a chance to start saving the American healthcare system. This is a formal Request For Proposals.

The lines are now open…