Tuesday, January 3, 2012

Commedia dell'Arte

"Accountability is something that is left when responsibility has been subtracted."
-- Pasi Sahlberg

This was the year when America turned on its doctors, and on itself. Not the 300 million citizens who are busy with other existential threats, but the elite 1% that effectively runs America, and the cadres of intellectuals who provide grant funded scientific cover to our leaders no matter how misguided they seem to be.  Health care is a fiscal mess and someone, other than policy makers, must be held accountable. The greedy little doctors who are over treating us to enrich themselves are a good target and so are all of us greedy little people who refuse to go peacefully and expediently into the night. The same strategy is being applied to education, with the pathetic self-serving teachers obsessed with their benefits and the misfit children who ought to be cleaning toilets instead of learning, identified as the culprits for our educational fiasco. Mind you, the elite 1% is not experiencing either education failures for their children, or health care difficulties for their families. For them, this is not personal, it’s business, and they are about to make us an offer we can’t refuse.

A hundred years ago, give or take a couple of decades, America delegated the responsibility for taking care of the sick to the medical profession, and as science advanced by leaps and bounds, people were greatly rewarded with better health and longer life, and doctors were rewarded with prestige and financial prosperity.  Some say too much prosperity, some say too little, but all in all, fewer than 10 cents of each health care dollar go to physicians. Professional responsibility for sick-care does not require one to be a saint and it is not necessarily incompatible with seeking higher remunerations for one’s services. However, something went very wrong along the way. Ever so gradually doctors have lost control of their profession to the rising corporate and public interests in health care who acquired complete jurisdiction over physicians’ reimbursements. Doctors became the servants of two masters, responsible for one and accountable to the other.

This obviously unworkable situation caused enormous problems during Managed Care I (the HMO). On the eve of Managed Care II (the ACO), our leaders are proposing, on behalf of the people, to release the medical profession from the moral and ethical responsibility which formed the foundation of the patient-doctor relationship and replace it with uniformly measurable accountability to public and private payers. Patients are advised to reject the old ways of paternalistic physician managed care, in favor of the empowerment afforded by payer, health system or employer managed care, which is certain to bring about better health care at lower costs everywhere except in Connecticut. Physicians, who enter apprenticeship as teenagers and graduate somewhere in their thirties, are having difficulty letting go of the historic burden of responsibility. Patients seem not to have read the official memo, and most are still expecting doctors to uphold their end of the ancient bargain. There are of course well publicized and well marketed exceptions.

While responsibility is entrusted, accountability must be managed, monitored and acted upon. From a patient’s perspective, the locus of trust must shift from the doctor to monitoring organizations. While the old trust was based on long term relationships, word of mouth or gut feelings, introducing much variability in outcomes, the new trust is based on facts, calculations and objective data, hence the controversial importance of Electronic Health Records (EHR), which are increasingly fitted to facilitate the transition from old to new.  EHRs too are the servants of two masters, used by one and governed by the other.

Early EHRs were built and sold to doctors as tools to enhance practice revenue and personal income. Interestingly enough, very few physicians found that proposition enticing, and EHRs did not sell very well. Today’s EHRs are prescriptive data collection tools, with budding capabilities for reporting and exchanging information, and largely promissory abilities to deliver relevant evidence based protocols at the point of care. As the Meaningful Use incentives program enters its second year, physicians are increasingly purchasing and using EHRs. A minority is truly excited about a digital future, but the majority of EHR users, and practically all those still sitting on the sidelines seem to be asking the same question: how does this help with patient care? Well, it does, and it doesn’t, depending on what one means by patient care.

Most physicians are looking at EHRs as tools to help them do a better job. These doctors are still under the impression that they are at the center of health care delivery and EHRs are tools to assist them discharge their responsibilities to their patients. They are looking to computers to help search a medical record in intelligent ways, abstract all pertinent information and no more, manage repetitive tasks on their behalf, deliver timely reminders, provide advice upon request and become invisible when not needed - in short, the perfect butler. This is about hands-on patient care, one patient at a time.

Those who govern EHRs are continuously harmonizing them, through the Meaningful Use regulatory system, to promote accountability of EHR users. They need data. They need boxes to be clicked, numeric values to be captured and buttons to be pushed, and they need everything compiled and transported out to analytics engines to assess performance or lack thereof. They don’t need to know about Mary’s Lasix trouble, but they do need to calculate the p value from paired t-tests for the average change in percentages between baseline and subsequent years across patients qualifying for the measures. This is about standardized patient care at the population level.

Today’s EHRs have some features serving their users, but most development is geared to serve the governors and as a result, EHRs are not able to please either one of their masters. As Managed Care II blooms and the doctors for the 99% transition to accountability regimens, minding their p-values and t-tests, EHRs will become fabulous engines for enterprise data collection and processing. When the powers to be come to the realization that government intervention based on the assumption that people are irresponsible, greedy, dimwitted and largely inconsequential is doomed to fail, and Managed Care II joins its predecessor in the annals of failed policy, EHRs will finally become slick, intelligent and nonintrusive servants to both responsible doctors and their patients, helping deliver better health care at lower costs, one patient at a time, and by definition across the sum total of the people, because technology is not the limiting factor. Responsibility is.


  1. I would also like to add that government involvment is why EHR software is now so expensive. EHR's that cost $5,000.00 4 years ago now cost almost $20,000.00.


  2. Hi James, good to see you here.

    I have not seen such drastic increases myself, but I did come across EMRs that doubled in price specifically on account of MU, and seen numerous vendors increase prices significantly by requiring that physicians buy additional MU modules.
    It's a captive market, I guess.

  3. Your first paragraph is a brilliant analysis of our current political situation. Congratulations on this insight!
    I also enjoyed your analysis of EHRs. It does seem that they are being pushed as a control mechanism rather than to improve patient care and that could explain physicians lack of enthusiasm.
    Hopefully, physicians will learn to take control of these things to help patients. (But I fear they will always have to "check the right boxes".)

  4. "I have not seen such drastic increases myself, but I did come across EMRs that doubled in price specifically on account of MU"

    Hello, Margalit. Glad to see you have a weblog, etc. You look remarkably like a husky, forgive me for saying so, based on the accompanying photograph. In any case, regarding the above, I have not been doing EMR (or HIE) related work for about 2 years, so missing in action on commentary, etc. However, I will likely be back to EMR work technically using PatientOS, since F\OSS and Java-based sometime later this year or in 2013. I agree the prices for commercial EMR systems are ludicrous and likely a function of the handout from the federal government.

    1. Hi Wendell,
      Not a husky. An Alaskan Malamute. Very friendly species....
      Glad to hear you will be rejoining the wonderful world of (expensive) HIT.

  5. That shows how much I know.

    As I note, I am pure F\OSS in regard to software development and will be using PatientOS among other existing F\OSS as a starting point. Unfortunately, the expected is happening in regard to the disbursement of tax-payer funds to reimburse physicians for implementing EMR systems. Oh, well.