This week’s New Yorker has an interesting article on how various countries developed their national health care systems. A few morsels…
“Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it.”
“There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.”
We’ll have to see what our friend Steve says about the author’s praise of the VA system (long known to be the most efficient user of IT in the health care world, though that’s rather like being a dwarf among midgets).
Most magazine articles and corporate breakroom debates about our healthcare system always focus on the question of *how* to pay for the medical care but I wonder how come nobody raises the question of “why”?
Why does a 5-day stay at a hospital hits you (or your insurer) with a bill of $65,000? That’s what my friend’s wife received in her mail two weeks ago. Also, I don’t understand why is high quality healthcare supposed to make nearly every doctor a millionaire with an office decorated with extravagant hardwood flooring. And why is it socially acceptable for a medical equipment salesman with a territory covering only about 3 million people to make so much on his markup to be able to own a private jet.
The issue isn’t private vs public insurance, the problem we’re facing is surreal medical costs. I was told that the same pacemaker, the exact same European model, costs 30-60% less in Germany than here, and the manufacturer actually makes a better profit. It was explained to me that in the US the same piece of equipment “has to touch a lot more hands” to make it into your chest.
Just yesterday my friend, who works at a hospital and was wearing scrubs, got literally attacked by an old crying woman in a grocery store because she thought he was a doctor.
The VA’s informatics system (VistA) is pretty impressive, but from what I’ve seen its success is somewhat context-dependent. In other words, a lot of stuff about it is VA-specific. I’ve heard several good success stories of people transplanting it to non-VA settings, but in every case there was a tech-savvy person involved who was also very personally committed to the project. It was by no means a turnkey solution. A couple of years ago I heard about a company that was planning on offering a VistA-based system to smaller, single-provider clinics using an ASP business model; I don’t know if that ever went anywhere but it seemed like a pretty decent idea to me.
When it comes to health IT, the first rule is that challenges (and successes) are usually about 5% technology-related and 95% politics/organization/workflow-related. One of the reasons that the VA’s been so successful for so long with IT is that they’ve spent the last thirty years or so making a serious effort at building it into all levels of their organization.
As a programmer, it’s tempting for me to attribute their success to the specifics of the technologies they’ve used and the software they built (they started using high-level, dynamic programming languages decades before anybody else, which gave them a big advantage in the early days). The real story, however, has a lot more to do with the administrators and clinicians who decided to make IT a real part of their clinical environment than it does the programmers and engineers who built the system.
Good software is a necessary, but far from sufficient, condition to successful health IT. Heck, it might not even be all that necessary: I bet that a hospital full of properly educated and motivated administrators and clinicians could probably get better results using nothing but Microsoft Excel than a hospital with a $20 million electronic health record system but bad administration could. Healthcare is the ultimate “no silver bullet” situation when it comes to technology.
I worked for a financial services startup that was nearly first to market with a Check21 solution in the early part of this decade. Processing checks electronically was so new at the time that the federal reserve bank had little idea how certain ancillary processes should work. We’d develop a method and test with them. They would think about it for a few weeks and come back with answers like “You’re doing it wrong…we don’t know what the right way is, so we can’t tell you why its wrong its just never been done like this, therefore wrong.” It was quite frustrating. And yet, our CTO who had actually written a hospital billing system in assembler back in the day would always shake his head and reply, “At least we aren’t in health care.”
I have never understood from a technical standpoint why good IT in hospitals is such a hard problem. Surely its massive in scale, but so is financial transaction processing. I managed a help desk in college for a campus with a large college of nursing. The dean of the school, as well as most of its students were all but computer illiterate. This is the closest explanation I can find for the current state of medical care IT. Why can’t I get all my medical records online and transfer them easily between medical institutions? Maybe because the staff at most of these places can barely cut and paste- but they can use the ultra sound machine (computer) like its an extension of themselves. They can spread your rib cage and massage your heart back to life, but seem afraid of even basic computer literacy. Perhaps when a newer generation of administrative staff takes over things will change faster.
I still am amazed that in New York, a pediatrician needs a whole office staff, while in Israel, I’ve been to a pediatrician that has a home clinic with no staff at all. The Kupat Cholim (perhaps that translates to HMO? There’s universal coverage, but a choice of plans called Kupot Cholim) has computerized records, so the pediatrician can fit the office in a small home – no files to keep. Records are available instantly and legibly. Every physician can see what everyone else has done, and even I can read the printed prescriptions. Even Xrays are given to patients on CDs.
The whole home clinic would be completely impossible in New York given any real space constraints. In Israel, the pediatrician just needs a free room. It’s hard to believe that their computerization doesn’t yield huge savings.
I am inclined to take the absence of any derogatory commentary on your part about the Massachusetts plan as evidence that you like it.
Niels: The U.S. health care system is such an expensive mess that I don’t know what to think or suggest. As a percentage of GDP, we spend twice as much as other developed countries and end up with worse outcomes. That has got to discourage business investment and job creation in the U.S. The Massachusetts system creates additional demand in a system already drunk on federal money and private insurance money. At that rate we’re heading toward a situation where everyone in the U.S. has health care, but nobody, other than government and health care workers, has a job.
Having worked in both VA and private practice for the last 15 years I can make some general statements but the convoluted mess of health care drops all potential reformers to their knees.
I have trained/worked in 4 VAs in different states and have seen much improvement in 15 years. It remains manager top heavy with multiple nonclinical people for each MD overseeing all clinical notes, prescriptions, labs, xrays, etc.. Much of this activity is done for the purpose of making sure the “quality measures” touted in the press are nicely polished. Patient care does improve as well since some of the suggestions made to the docs prevent possible errors such as drug interactions.
The electronic paper work at the VA is overwhelming. In private practice I have a staff dealing with typing, faxing, filling out paperwork. At the VA I often do these activities myself with a corresponding drop in number of patients I see in a day. Outside of the VA I may see 28 people/day. At the VA 17 is the norm which seems very busy and allows 5 minutes for lunch while typing. In defense of the VA the patients are usually more complicated and require more time.
The VA electronic records continue to evolve. 15 years ago down time was common with limited capabilities. Today downtime is rare. The current capabilities can be impressive with abilities to look up xrays, labs, notes, ekgs but the patchwork system has a long learning curve to be proficient with the deep menu system. The ability to get records from other VAs around the country is rapidly growing but is cumbersome as well. Electronic Medical Systems being implemented here locally are expensive, technically challenging, and constrained by HIPAA privacy rules.
http://en.wikipedia.org/wiki/HIPAA