Sunday, July 5, 2015

The Tower of Babel and Consumer Confusion

Are you confused yet  ? I am.  No one is telling me that my health and health care are better than it was twenty-five years ago. We've spent billions of dollars on improving our health system however today it is much more complex. We are told that knowledge has grown and readily available for the asking on the internet,  and mobile devices.  Interestingly television is not even on the map.

Medical education has shifted. At one time having an M.D. was sufficient (in addition to a specialty training program) however now an M.D./MBA carries more weight.  It took me about 10 years of belonging to my own C-suite running a medical practice to earn my O.J.T.  credentials.  That in itself should be worth some type of certificate and/or CME credits.

Where do you go when sick ? Do  you call  your M.D, or seek an E.R. or urgent care clinic ? Perhaps you 'Google' your symptoms or disease for an answer.When and if secure email becomes readily available you can email your doctor for help.

Eventually your M.D. will see a pop-up notification from your EHR and/or PHR indicating you need an appointment. Then you will receive an automatic response with a time and date. There will be no or little human-human interaction. Once you arrive at the office you will sit down at a work station that weighs you, takes your pulse, BP, and temperature. A skin sensor senses  your blood glucose and electrolyte levels as well as kidney and liver function tests.

Today we are not at that level, and are wandering in a sea of confusion about it all. Patients and consumers are overwhelmed, as most of we physicians are.  No one quite know what technology to invest in that really matters or improves quality and/or outcomes. It seems to obsolete itself every five years or so, fueled by governmental regulations, and intense marketing by device manufacturers, or software vendors..

Meaningful use has devolved into meaningless spending.

John Lynn writes at EMR & HIPAA, which you can subscribe to here.
His topic gels with my own thoughts about Health Care Confusion.

Confusing the Consumer – Defining New Healthcare Roles


Musings on Connected Health by Joseph Kvedar, MD


 As we continue our journey to change provider reimbursement to a “Pay for Value” system, the lines between health insurers and health care providers are blurring. Physician/hospital systems, like Partners HealthCare, where I work, are taking on risk for populations of patients through contracts with the Federal government and local payers. According to Secretary of Health & Human Services, Sylvia Burwell, this trend is going to continue. She stated recently that HHS set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. Since the whole insurance industry is based on risk, we inevitably have to start thinking more like insurers if we’re going to be taking on risk.  Sadly, I didn’t learn much. Not because I didn’t listen and not because the speakers were less than talented. I walked away feeling like I hadn’t learned anything because I felt I had gone to a foreign land and was listening to talks in a foreign tongue. I simply couldn’t decipher the health plan lingo.
Is this our inevitability, from Genesis?
As the King James version of the Bible puts it:
4 And they said, “Come, let us build ourselves a city, and a tower whose top is in the heavens; let us make a name for ourselves, lest we be scattered abroad over the face of the whole earth.”
5 But the Lord came down to see the city and the tower which the sons of men had built.
6 And the Lord said, “Indeed the people are one and they all have one language, and this is what they begin to do; now nothing that they propose to do will be withheld from them.
7 Come, let Us go down and there confuse their language, that they may not understand one another’s speech.”
8 So the Lord scattered them abroad from there over the face of all the earth, and they ceased building the city.
9 Therefore its name is called Babel, because there the Lord confused the language of all the earth; and from there the Lord scattered them abroad over the face of all the earth.
—Genesis 11:4–9[1]

Are we pursuing the ultimate perfection in health care? Can perfection be the enemy of the good?
An aphorism which is commonly attributed to Voltaire, who quoted an Italian proverb in his Dictionnaire philosophique in 1770: "Il meglio è nemico del bene".[2] It subsequently appeared in his moral poem, La Bégueule, which starts[3]
Dans ses écrits, un sage Italien
Dit que le mieux est l'ennemi du bien.
(In his writings, a wise Italian says that the best is the enemy of the good) 



"Better a diamond with a flaw than a pebble without."
Confucius,attrib.[1]







At the highest level, it seems like we should be natural collaborators, as we bring very complimentary skills to the shared goal of building a health care system. As providers, we excel at understanding physiology, pathophysiology diagnosis and therapy. In most cases, we have strong relationships with the end users of the services offered, our patients, which often includes a high degree of trust. When someone’s doctor recommends a course of action, most people at least take it seriously and many often follow that path.
Payers, on the other hand, have always been challenged connecting with their members (you see, we are all a member, a consumer and a patient – all in different contexts – an example of the babbling). Payers excel at understanding risk and setting premium costs, something we as providers have no feel for. But if we’re going to take on risk, we’ll have to learn. Can these former negotiating foes come together to help improve your health? The current landscape does not lead to enthusiasm.
I’ll use some telehealth implementations as examples. Several national payers are adopting virtual visits as a tool for their members. For me, this is a dream come true! BUT, most payers are doing so in collaboration with one of the major vendors in the space and creating shadow physician networks to offer the service to their MEMBERS. When that member’s primary care doctor eventually sees them in the office, she will be puzzled that her PATIENT had an encounter via their health plan that she did not know about.
Walgreens just rolled out a virtual visit program as well. This could create even more confusion, as it brings in a new entrant — the pharmacy — into the battleground for that relationship. Will EMR interoperability solve this confusion? It certainly helps, but I’m also concerned about mixed messaging to the consumer/patient/member. It seems like we’re all fighting for your attention, which may lead to conflicting messages.
This reminds me of a time, about 25 years ago, when this new thing called disease management sprung up. Payers were frustrated by the cost of managing patients (members) with chronic illness. They got no help from providers, so they took matters into their own hands, hiring call centers staffed with nurses to contact patients/members with tips on how to manage their illness, and often sent generic brochures about high blood pressure and other conditions. Payers may have influenced the care of some patients/members, but no one was ever able to prove that this was an effective strategy.
There were numerous stories about patients receiving conflicting advice from these ‘disease managers’ compared to their own doctor’s advice, leaving patients confused. Doctors would get faxes from these same disease management companies and (perhaps arrogantly) throw them in the waste basket without reading them. As a result, the disease management industry collapsed in the middle to latter half of the last decade.
In the meantime, we now have workplace wellness programs, virtual visits offered by your health plan, retail clinics, virtual visits offered by pharmacies and — dare we forget — advice your doctor gives you, which should be more in tune with prevention now that providers are taking on risk.
See what I mean by a Tower of Babel? How do we fix it?
Adding to this conundrum we face increasing health information technology guiding consumers on another journey via a personal health record, a clinic portal, and numerous websites on disease, symptoms, and treatments.
In the near future "Watson" looms, a portender of artificial intelligence developed by IBM.

John Lynn concludes:

Joseph’s comparison to the Tower of Babel is a good one. The solution to all these new healthcare modalities is to make sure that everyone is speaking the same language. It doesn’t solve all of the problems, but it does help everyone get on the same page. I just hope that the business interests of many involved in healthcare don’t get in the way of this goal.

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