Saturday, November 04, 2006

Do we need profound changes now?

On another blog, I’ve been arguing about the need for profound changes in our healthcare system, and to make these changes sooner than later. I proposed is a multifaceted, consumer/patient/community-centered, knowledge-based, collaborative wellness strategy (defined in our WellnessWiki), which focuses on changing the current policies, processes, and practices that reward mediocrity and punish efficiency. This strategy takes a comprehensive approach that would implement a number of tactics that foster continuous improvements in care safety, effectiveness and efficiency by dramatically increasing our clinical knowledge and ability to use that knowledge with the ultimate goal of ensuring every person gets the precise sick-care and well-care needed when it is needed -- nothing more & nothing less -- and to make sure that care is delivered competently and cost-effectively. It is based on an attitude of forever seeking perfection. Executing this strategy would require spending money and time on a transformational process that (a) constrains wasteful, fraudulent and error-prone aspects of our current healthcare system and (b) expands aspects that generate high value, i.e., promotes excellent outcomes with the least necessary utilization of resources.

The main rebuttal to my proposed strategy is that there is no need for profound changes since our healthcare system is fine the way it is -- there is not healthcare crisis, it’s largely media hype. We should, therefore, let things change incrementally (step-by-step manner) as they have in the past. After all, we’ve made great strides in our healthcare technologies, medicines, and procedures over the years and will continue to do so if we just let market forces do their thing. And on top of that, our country doesn’t have the money to drive profound change with comprehensive strategies even if we wanted to do it. So, instead of discussing comprehensive strategies, we should limit our focus to a few tactics aimed primarily at controlling costs without spending a lot of money in the process. In terms of dealing with safety problems, it was suggested that we settle for now on getting rid of dangerous providers.

I will briefly discuss how I responded to each of these and look forward to you comments.

The vast majority of healthcare providers are intelligent and compassionate people who work very hard and do the best they can in a broken system that reward mediocrity and waste. Dedicated researchers have made wonderful breakthroughs in medicine, genetics, and medical devices that help keep us alive longer than ever with an improved quality of life. And health IT companies are developing ever better tools. Nevertheless, there is a healthcare crisis as discussed here and here.

While I agreed that changes should be done incrementally since we can’t do it all at one time, and while I agreed that we’ve made great advances over the centuries, I argued that the incremental changes should be accomplished whenever possible with leaps, not baby steps. The first leap would be to develop a “big picture view” of all the complex interacting problems with our current system. The second leap would be to use this broad & deep understanding to define and endorse a comprehensive strategy detailing all the changes necessary to solve the healthcare crisis in ways that bring the most benefit to the most people, including universal coverage and continuous quality improvement. The third leap would be to prioritize the tactics from most to least important and likely to succeed. The forth leap would be implement those tactics. And the fifth leap would be to learn from our successes and failures in a knowledge feedback-loop process that continually improves the strategy and tactics.

One reason for leaping ahead with a sense of urgency, imo, is that failure to do so will just prolong and exacerbate our problems by fostering inertia and complacency. I say this because our country has a tendency to seek superficial, short-sighted, failure-prone solutions designed to maintain much of the status quo; we tend to shy away from profound changes that “rock the boat.” Secondly, if we have the technical ability to make profound improvements in care safety, effectiveness and efficiency – which I claim we do – then why wait? Is it because we lack the will? Lack the money? Lack the leadership? Are afraid? All these things? Probably. So, shouldn’t we be focusing on ways to overcome these constraints, rather than giving into them without a fight?

Let’s assume for a moment that we have the will, courage, resources, and leadership to realize profound change. What might we focus on first so we can deal with the healthcare crisis in “bite sized pieces” rather than all at once?

Well, a majority of healthcare spending in the U.S. has been attributed to people with chronic (lifelong) conditions that can be especially difficult and expensive to treat, especially since patients do not always comply with the medical regimens, and because they may have multiple comorbidities for which evidence-based guidelines don’t exist, and there are difficulties coordinating care among many different providers working with the same patient. What should be done?

I suggested that one key factor common to dealing with all this is knowledge. Treating chronic and complex conditions safely, effectively and efficiently requires that we know a great deal about such things as: (a) patients’ problems, strengths, weaknesses over extended time periods, including physical and psychological signs & symptoms, genetic markers, attitudes and emotions, social support networks, etc.; (b) patients’ preferences (e.g., regarding quality of life issues as related to the consequence of treatments); (c) appropriate evidence-based guidelines and how to implement them; (d) self-care methods and motivators; (e) patients’ medical history; (f) what all the providers treatment a patient are doing so care can be coordinated across the entire healthcare continuum; (g) the effectiveness of care delivered through ongoing feedback; (i) whether medications prescribed are contraindicated (e.g., are likely to cause unacceptable side effects or and adverse event by interacting with other meds); (j) providers most qualified to deliver the care; etc.

Obtaining and using this knowledge effectively may require: (a) a commitment to ongoing clinical research; (b) development, evolution, and dissemination of evidence-based guidelines (including outcomes studies and consensus conferences); (c) cooperation and collaboration among healthcare professionals; (d) case management; (e) information exchange technologies (including interoperable EHR/EMRs); (f) next-generation personal health records (PHRs) that give patients ongoing feedback and reminders; (g) clinical decision support technologies (including diagnostic aids); (h) clinical guideline and outcomes research technologies; (i) patient education technologies; (j) methods for fostering patient compliance; (k) provision of mind-body medicine (e.g.,; (l) transparency tools; (m) greater understanding of complementary and alternative interventions; (n) patient advocacy; and more. An enhanced disease management program would offer some this (see http://curinghealthcare.blogspot...-and-what.html/).

This is a comprehensive solution of profound changes. But not everything needs to be done at once, and not every patient needs it all. The objective would be to make it all available as soon as possible, so every patient could get what they need when they need it.

Some of the most pressing things to do, imo, are to administer comprehensive biopsychosocial diagnostic assessments, use and evolve existing evidence-based guidelines and develop new ones that address multiple comorbidities, enable better patient data sharing, provide ongoing feedback to patients about their health status and maintenance, learn how to motivate patients to comply with the medical regimens, develop and use effective decision-support tools, implement patient safety processes, supplement sick-care with well-care, and empower consumers to select the providers and health plans best suited to their needs.

I don’t see this as being biting off more than we can chew, but I do think it requires profound changes. Can our country afford to pay for these profound changes? Should we even bother discussing how to do it? Are there easier and cheaper solutions worth consideration? What do you think?

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