My Family Health Portrait

Just in time for the holidays, the Office of the U.S. Surgeon General together with the National Human Genome Research Institute (NHGRI) has developed a Web site to organize and display family health history: https://familyhistory.hhs.gov/. Despite the overwhelming numbers of Americans who believe that knowing their family's history is important to their own health, very few have collected and organized this information. This new software makes it easy to input and report this information.

No information is stored on the site; the user downloads it at the end of the session. You may even download the software for use on your own computer. Outputs are either in report form or in a graphical family tree structure. At this point you may wish to conduct your own genetic analysis or take the report to your family doctor which will provide her with greater insight into your predisposition to genetically linked diseases.

Predicting the Future

If we could accurately predict what the price of a publicly traded stock would be tomorrow we would stand to make millions. We all know that we can't do that or even simpler predictions. But there are more general predictions that we can make that are just obvious; drugs will continue to improve to provide better healthcare benefits, computers will become better integrated to provide a more seamless interface with our lives.

I've been reading Neil Stephenson's book Snow Crash; an action, adventure, video game like view of the future. Probably not one of Stephenson’s best, yet the thing that struck me was that it was first published in 1992, really before the modern Internet, before the advent of serious computer virus' and certainly before Second Life, yet it's all here as if he had some portal into the future. Granted many of his predictions have yet to fully come to pass, he was probably shooting for 2020, but some of them are well on their way.

One prediction that Stephenson and other futurists make without fail is the ability to access multiple data sources seamlessly, i.e. by using a single interface users can quickly and easily access a multitude of data sources and mix and match the gathered data. It seems so effortless and so obvious. Yet in the real world the notion of this level of integration would be met with questions regarding the substance in your cigarette. We have created so many isolated and discordant systems that the effort of tying them together seems hopeless.

This is why we can marvel at systems such as Google which appear to make sense of it all. These search engines can seemly extract the needle from the haystack, which is in fact amazing, but falls far short of the real value of the Web. Far too much manual munging is required to get the information into something even remotely integrated. Start your own database and integrate to it? A workable solution, but just a drop in the information ocean.

If the rest of the Web insists on remaining silos, at least some visionaries are creating integrated environments, i.e. facebook. facebook is creating an integrated Web within the Web and members seem quite content to stay within its bounds. Relatively small now, it will continue to grow rapidly as third party applications add more value to the integrated environment. An entertaining toy? Maybe, but it may provide a glimpse of how other domains may provide integration.

How Doctors Think

Jerome Groopman, M.D. has taken on the arduous task of penetrating the minds of physicians in his latest book How Doctors Think. As I am always interested in knowledge management in the healthcare and life science industries, I was intrigued by the topic and have been reading the book. What is of primary concern to me is: given the vastly increasing amounts of information that physicians must consume and process, how can they best leverage this knowledge to improve patient care? Groopman offers little if any advice in that realm. "Keep an open mind," "listen to your patients," are all good suggestions but how and when does the physician keep up with the latest in advances in the field?

Groopman's driving concern is the accuracy of diagnoses; only by properly diagnosing a disease can it be effectively treated. This is fundamental to the practice of medicine and a principal which everyone in the healthcare industry can agree. Groopman then cites many cases where diseases were improperly diagnosed and why. He points out the differences between medical mistakes; technical errors such as picking the wrong leg to amputate, and misdiagnosis; a result of flawed medical thinking. He cites a study that states that the majority of errors in healthcare delivery were due to misdiagnosis.

Although better information management may reduce technical errors, medical mistakes, Groopman feels that electronic medical records may increase cognitive errors; errors created by flawed thinking. He feels that technology drives a wedge between the doctor and patient and encourages the type of mistakes he's seen in his studies. These errors are a result of an early misdiagnosis or framing which has been allowed to continue without question throughout the patient's case. EMR give an artificial appearance of legitimacy to doctors' notes which may result in propagation of cognitive errors.

Groopman sees this as black and white; EMR are dangerous and should not be used because they commoditize medicine and will result in more misdiagnosis. There is no question that there is a push to control, if not reduce, medical costs. To do that requires improving efficiency, automating and streamlining repetitive tasks is one of the first places where this can be done. Early EMR systems may have reduced a physician's ability to think freely constraining the diagnosis process but as systems evolve, and physicians provide more input, EMR systems will become less of a wedge and more of a bridge between physician and patient.

To alleviate the problem of the physician staring into the computer screen and not looking at the patient, how about a wide screen monitor in the exam room where both the physician and patient can look at the record together? Would this result in longer exams as the patient goes through each and every note? If the interface is well designed the patient should be able to grasp the information quickly. One day this information will be owned and controlled by the patients themselves giving them ample time to view it on their own schedule.

Perverse Incentives

In a recent piece in the Wall Street Journal entitled Perverse Incentives in Health Care, John Goodman describes the environment in today's healthcare system that disincentivizes efficiency and quality in healthcare and rewards the status quo. Goodman places the blame for this on a system in which the payer calls the shots; Medicare or the insurance companies dictate what procedures they will authorize and how much they will pay for them. It's the healthcare providers' job is to provide the best care for their patients while staying within the boundaries set by the payers.

This has the effect of reducing and discouraging any innovations in the field because the provider may not be reimbursed for them. If a healthcare provider, medical device or pharmaceutical company has a better, more efficient or effective way of treating a patient this must be reviewed and approved by the payers before a healthcare provider can get paid. Although it is in the long term interest of the payers to reduce costs and improve quality, they are large bureaucracies and do not respond quickly to changes in the market. As a result such innovations as email and electronic medical record systems are not as easily implemented in healthcare as they are in virtually every other sector of the economy.

Goodman points out that those sectors of healthcare that are not reimbursable but rather paid for directly by the consumer, such as cosmetic or laser eye surgery, are both competitive and entrepreneurial. These sectors offer competitive and dropping prices, rapid gains in technology and constantly improving quality. In these sectors the coupling between payer and provider is looser; the consumer is simply interested in a smaller nose, better eyesight or fewer wrinkles and does not want to sweat the details of how much a syringe, anesthetic or some sub-task costs.

Some healthcare providers, such as the Mayo Clinic and Intermountain Healthcare, have bucked the system and have implemented efficient practices resulting in dramatically reduced healthcare costs. This requires not only vision, but a large investment of resources to implement. Most healthcare providers are too constrained by their current financial situation to take such a risk. Goodman suggests a way for Medicare to reward innovations that will lead lower costs in the long run. It may be a start, but the whole idea of a government agency managing innovation strikes me as equally perverse and ultimately futile.

What's Next, House Calls?

A story on the front page of yesterday's Wall Street Journal describes a physician in Rochester N.Y. who started up a solo practice with just an office and a computer. After working as a staff doctor in the local hospital for eight years, Dr. Gordon Moore figured it took 19 separate actions and 253 feet of walking just to order a prescription refill. With his new software he can order a refill with a few clicks and zero feet of walking. What's wrong with this picture?

The implementation of EMRs in clinical environments is often met with anxiety, resistance or ambivalence. Due to compelling economic pressures on large hospitals they are placed in situations where they are obligated to implement the systems, often at high expense and risk. Smaller practices take a wait and see approach; the economic need is not seen as so compelling as to off set the risk and the pain of implementing the new systems. As I explained in an earlier blog, some of these practices have needed significant subsidies to get their systems up and running.

But when you have an important medical service, such as primary-care healthcare, saved from dwindling numbers of care providers by the implementation of technology, the benefits are undeniable. The key is to find the right combination of systems to fit the current and near-term needs. This may be easier in a solo practice than one with multiple physicians with conflicting needs or perceptions.

Healthcare's Portion of GDP

The U.S. Centers for Medicare and Medicaid Services recently published their health expenditure data for 2005 indicating what we all expected; that healthcare costs continue to rise. But what is perhaps even more pertinent is the rise in the percentage of the GDP healthcare consumes; 16% in 2005 up from 15.9% in 2004 and 13.7% a decade ago. At 16%, the U.S. leads the world in the percentage of our GDP we spend on healthcare, second place Germany spends 10.5%. This means we either have the absolute best healthcare in the world or a pretty inefficient way of providing healthcare to our citizens. The Organization for Economic Cooperation and Development which monitors metrics in determining the health of a country, such as life expectancy and infant mortality, do not indicate the former.

The implication then is that the healthcare system is inefficient. This of course is the topic of many a debate in the government and healthcare industries but what is not under debate is the aging of the baby boomers, now reaching their 60's, and the ensuing increase in demand for healthcare services that they will require. With the healthcare system in its current state I see healthcare costs per capita continuing to rise at least for the next decade. Justin Lahart in his column Ahead of the Tape in the WSJ has suggested that Washington and state capitals will focus on the problem and thus bring the price down. How? The White House plan is to move toward the free market approach; allow the consumers to pick up a higher share of the costs of their healthcare which will in turn put pressure on providers to become more competitive. This entails the reduction in tax breaks on generous healthcare plans provided by some employers to their employees. Economists point out that this encourages these people to use excessive amounts of healthcare which drives up the overall costs.

Under the White House plan health benefits would be considered income and subject to income and payroll taxes. There would, however, be a deduction of $15,000 per family per year or $7,500 per individual. The same deduction would be available whether the coverage came from an employer or the individual.

Although many details still need to be worked out in this plan, making the consumer more responsive to healthcare costs is certainly the free market approach to controlling ever increasing healthcare costs. In a true free market of course, the consumer would negotiate the costs directly with the provider thus putting pressure on the provider to keep costs in check. But with the high costs of healthcare and its extremely variable distribution among the population, a third party payer system seemed like the most reasonable way to handle the situation. This system has short-circuited the free market checks and balances which has reduced competition among healthcare providers and thus reduced their need in seeking efficiencies in keeping costs down. The result is as expected: costs in healthcare have risen faster than the of costs in the economy as a whole without a commensurate rise in healthcare quality. Although providers may be assumed to have the best of intentions, only economic pressures will force them to make the hard choices required to reduce waste and improve efficiency.