Tuesday, October 16, 2007

Patient-Centered Life-Cycle Value Chain: the Emergency Care link

In my last post, A Path to Profound Healthcare Transformation, I discussed how our low-value healthcare system is built upon our country’s pathologically mutated form of capitalism. I then described a new direction for transforming the current broken system into a high-value patient-centered system that delivers top quality care and does it efficiently and at a good price (i.e., cost-effectively) over a person’s entire lifetime.

This past week I came across two more articles that support my call for value to the patient.

The first one, Healthcare 2015: Win-win or lose-lose?, reported that:

Healthcare is in crisis…[and] will become unsustainable by 2015…

Value is in the eye of the purchaser, but today value in healthcare is difficult to see. Data regarding the healthcare price is tightly held and difficult, if not impossible, to access or comprehend; quality data is scarcer still and mostly anecdotal or incomprehensible. To complicate matters, the purchasers and benefactors of healthcare – consumers, payers, and society – all have different opinions as to what constitutes good value. Balancing and resolving these conflicting perspectives is one of the major challenges in the successful transformation of healthcare systems.

Today, consumers often have little direct responsibility for bearing the costs of healthcare and their ability to predict healthcare quality is equivalent to a roll of the dice. Payers – public or private health plans, employers, and governments – shoulder the burden of healthcare costs, but often incentivize poor quality care in pursuit of reduced episodic costs. Societies tend to pay little attention to healthcare costs or quality until service levels for healthcare or other societal ‘rights’ are threatened.
I contend that the only way to deal with our healthcare crisis is by defining value from the consumer/patient point of view, as well as enabling us all to obtain cost-effective care and be rewarded for doing so. In addition, providers and insurers who deliver the greatest value to the patient/consumer should enjoy competitive advantage and reap greater profits.

The second article, titled Survival Plan--which is written by a fine author, Maggie Mahar--reports how the Medicare Payment Advisory Commission (MedPac) warned that:
…unless Congress makes some hard decisions about how to contain health-care spending, Medicare won't be able to sustain its current program -- let alone expand coverage to the entire nation…if Medicare continues spending at the current rate, it will hit a wall in twelve short years: At that point, the trust will be able to cover only 79 percent of Medicare's costs. …Billings from physicians [have been] spiraling, largely because the volume and intensity of the services they provided were rising. This was in part because …Medicare pays physicians fee-for-service. The more they do, the more they are paid. In other words, the financial incentives of the fee-for-service system reward quantity, not quality.

Many physicians argue that in recent years they have been forced to "do more" just to maintain their income stream. While the cost of real estate, supplies, and malpractice insurance climbs, their fees have not kept up. They must make up the difference, they say, "on volume." Few consciously over-treat patients, but many see more patients more often-- which means that those patients receive more tests and treatments, and Medicare receives more bills…from 2000 to 2006, Medicare spending for physicians' services rose by more than 9 percent annually.

… In some parts of the country, Medicare spends twice as much per beneficiary as in other parts… In high-spending regions, patients undergo more tests, spend more days in the hospital, and are far more likely to see ten or more specialist during the final six months of life -- for reasons that have little to do with either medical necessity or patients' druthers… And here is the shocker: Patients who receive the most aggressive care fare no better than those who receive more conservative care. In fact, often, outcomes are worse.

…[One suggested solution by MedPac to Congress was to] abandon "fee-for-service," and pay physicians for quality and efficiency. Those who achieve the best outcomes -- while using fewer resources -- would earn more. …Long-term, this could lay the foundation for high-quality, affordable care.
So, the need to bring patient-centered value to our healthcare system is critical! Our Patient-Centered Life-Cycle (PCLC) Value Chain is a sensible path for our country to follow.

I previously said that integrating emergency care, sick-care and well-care is the cornerstone of the PCLC Value Chain. This is because high-value to the patient means receiving the care you need when you need it, including:
  • Emergency care through emergency management if you are in an accident or if you are by a disaster site
  • Sick-care if you are ill and need to see a doctor
  • Well-care if you want to avoid becoming ill through prevention, and to keep chronic conditions (like diabetes or heart disease) from causing complications or premature death.
In this post, I will discuss emergency care from a PCLC Value Chain perspective. My subsequent posts will focus on sick-care, well-care and the integration of all three. After that, I will focus on describing the clinical and financial processes the need to be reformed, followed by the infrastructural needs surrounding health information technology use.

Emergency Care Through Emergency Management


The first link in the PCLC Value Chain involves emergency management. In an emergency, especially in a widespread disaster, saving lives and property depends on the timely exchange of information between command & control units, 1st responders (fire fighters, police, EMTs, trauma center staff, etc.). Our current system has failed in many areas, as witnessed by the Katrina and 9/11 disasters. We are vulnerable; the threat is real. Systemic changes needed to handle disasters include establishing Emergency Information Exchange networks that enable the following:

  • Identification of the safest routes to and from a disaster site. We have to assist 1st responders in finding the safest routes to the site of a disaster, as well as the best routes for transporting rescued victims from the triage point to a trauma center. This requires obtaining environmental data (including roads and air) from the DOT, NOAA, FEMA, CDC, etc. to help identify the best routes for emergency vehicles to take to and from the disaster site.
  • 1st responder and victim location, tracking and least-risk extraction: We have to improve the assistance given to 1st responders as they attempt to find and extract victims from the disaster area, including rescues from destroyed buildings. This requirement involves helping them locate victims, identify safe routes to and from the victims, as well as tracking the location of the 1st responders themselves in case there is a “man down” situation.
  • Victim triage, transport and tracking: We have to do a better job assisting EMTs (emergency medical teams) in evaluating victims’ conditions and initiating emergency care at the triage point. In addition, they must have help determining appropriate transport locations, as well as tracking victims as they travel from triage to trauma center.
  • Durable and reliable communications between 1st responders, trauma centers, and all other emergency personnel: We have to enable real time connectivity and clear communications between emergency personnel in real time using systems that work well even when broadband is down and the Internet is unstable. Sometimes only “spread spectrum” radio communication will do, but even that can be blocked by the structures of a high-rise building. In addition, conversations between multiple parties using the same communication frequency (i.e., “chatter”) make it impossible to understand what’s being said. So, we need a system that connects individuals in close proximity to one another and in a way that blocks out unwanted chatter.
  • Integration of disparate data in real time and the ability to share the data in user-specific composite reports: The information that emergency personnel need must be obtained, in real time, from disparate data located in many different repositories. These data must then be integrated to generate composite reports, which are tailored to each person’s particular needs.
  • Monitoring and managing resource use with instruction, reminders and alerts: We need a better way to monitor and manage trauma center (and other hospital) resources through delivery of instructions, reminders and alerts. This includes using efficient and effective means to:
    • Establish plans of care (PoC) using evidenced-based practice guidelines and track their implementation
    • Alert authorized staff when PoC orders are due to be implemented, as well as when the failure to implement the orders in a timely manner are likely to cause problems in the care of other patients
    • Evaluate required against available resources to determine if there are adequate staff, beds, medications, equipment, supplies, etc. to care for patients’ entire length of stay, and notify authorized personnel when resource shortages currently exist or are projected
    • Enable resources to be increased or PoCs to be adjusted in order to account for resource shortages
    • Generate reports showing healthcare delivery performance and giving insight into ways to improve the performance.
  • Transition from paper records to electronic health records: Paper-based health records, that haven’t already been destroyed, are of little use in a disaster. This is why we must speed the transition to electronic health records.
In my next post, I examine the second link in the PCLC Value Chain: Sick-care.

Print this post