It is time to burst this wasteful and distracting bubble.
Witness the Findings of a 10 year Effort By Robert Wood Johnson Foundation
"A key finding within the supplement stems from the evaluation team’s efforts to determine if AF4Q improved population health and health care quality measures. The evaluators found no major improvements in these measures within AF4Q communities compared with control regions." After ten years and 300 million dollars, this would tend to point to the need for different investments.
Not surprisingly there were not significant changes. This was likely because there were no changes in the population or as noted, all populations (study or control) were changing the same. The intervention did not work for the main purpose.
It is a great complement at this time in history to report no difference. RWJF has demonstrated integrity in this reporting. This may not seem like much but it is unprecedented across other foundations, associations, and government. There was success in consumer focus, but not population health or changes in health care quality measures.
Instead of finding a way to report success and jump on the HITECH Bandwagon, objective scrutiny prevailed.
Time to End the Era and Error of Medical Error Focus
Grandiose claims in health care used to be unusual, but no longer. It has become difficult to believe claims of any kind. Even if results look poor, adjustments can be made to obscure the obvious.
Health care quality has not improved. This is not a shocker since the outcomes are predominantly about people and not about their providers, or lack thereof. Because costs have increased and quality has not improved, the nation has moved to lower value - despite attempts at higher value.
Primary Care Medical Home costs $105,000 more per primary care physician with minimal if any gains. This also is the opposite of value.
MU to MACRA has added tens of thousands more in direct costs per team member per year and creates more consequences. Even the best methods used when you can assign a provider to a pateint to an outcome (very rare) cannot discern quality.
Grandiose Eras Come Crashing Down
Grandiose advances in science, economics, and industry have come crashing to the ground before. Twice the world economy has been taken down with the aid of new technologies. Grandiose creations have also ended up on the bottom of the sea.
National Geographic has been working diligently to capture the many aspects of the wreck of the Titanic and the lessons that we must learn. The Titanic represented more than an unsinkable ship that sank.
James Cameron has spanned the heights and depths of this planet, and perhaps the heights and depths of humanity as well:
“The Titanic disaster was the bursting of a bubble,” James Cameron told me. “There was such a sense of bounty in the first decade of the 20th century. Elevators! Automobiles! Airplanes! Wireless radio! Everything seemed so wondrous, on an endless upward spiral. Then it all came crashing down.”
Technology is only as good as its limitations. Physicians must learn what they know and what they do not know, what they can do and what the cannot do. Health care, software, and other innovators have no such focus.
- Titanic killed hundreds via pick your choice of - full speed ahead, no need of safety devices, calm night without white breakers to see the bergs, cheap materials...
- But now we have developed massive capability to cause harm by diverting scarce resources to technology, by overcharging for technology, by using technology for regulating health care, by diverting more dollars for care of a few people in a few locations at extremely high cost
And because of all of the wondrous technologies of then and now, the whole world knows about spectacular failure. Unfortunately it seems that this fact is often ignored by the designers.
HITECH Failures from the Start
HITECH was integrated into the Recovery Act - into the trillions of additional debt instantly created. The HITECH component did not actually result in spending our way out of depression since it took much time. The software was not ready either.
HITECH also boosted the careers of many individuals into positions of enormous influence - as seen in Commonwealth Foundation President David Blumenthal MD. It is not surprising that the priority mission of access to care has disappeared in favor of insurance coverage and technology focus.
Dollars do shape new leadership, and not always in the direction best for overall health or health care. This example brings back memories of drug company money that went into cholesterol drugs and research and soon the researchers were department chairs, deans, and other leaders in health care.
Even worse, when the digital health revolution has fallen short time and again, and even when CMS leaders admit failure as in Meaningful Use, the government has doubled down to even greater cost to providers and to the nation. There was not even a pause for reflection.
How much more can care givers take? They already devote 2 hours to EHR for each hour of care delivery. Innovators are quick to point out that scribes can be hired to do the work, but how is this helpful for negative margin practices or for populations already hurting because of too few team members to deliver care?
The overall result has been even greater declines in health workforce productivity, declines in morale, accelerating burnout, and even greater distraction from delivering care.
Never in the history of the United States has so much time, talent, and treasure
been diverted from the actual delivery of care and from the support of the team members to deliver the care.
How has it been possible for the focus of Health Care to be diverted away from health care delivery?
A first diversion from health care to other interests involved the cost cutting focus - the invasions of the bean counters and spreadsheet gurus. These are the ones who calculate the savings to be made without consideration of the costs inside or outside of health care. An example is 22 times greater cost than saved due to impacts on mental health patients just because someone figured out how to shave a few bucks per person per month by changing Medicaid from 7 prescriptions per month to 3. This was just the emergency care, hospital care, long term care costs and did not even include the non-health care costs. The experimentation continued with co-pays and approvals of medications and other restrictions - with additional consequences for patients (death, disability) and for providers.
In recent years the cost cutting has been merged with quality measurement focus. This is a difficult combination to crack. If you oppose this, you are painted
- as against progress
- as part of the wrong political party
- as against quality
- and worse
The attempts at micromanagement have resulted in a failure to grasp the big picture of what is going on. The cry of "better quality" has diverted attention from the team members who interact most with patients. The incentives to change behaviors have impaired the basic behaviors most important for patient interactions.
To Err is Human Is the Appropriate Theme
Those who have cheered on the worship of technology are human and have erred in their zeal. The result has been rapid and poorly considered massive change. From the very start, the experts have had high hopes, high costs, and high failures. Human individuals are much more complex than can be captured by measures and the endless permutations of relationships are far beyond computation and comprehension. The wreckage is laid out to see just like the ruins of the Titanic. Like the Titanic the effort seemed Too Big to fail and failed titanically.
There is gathering evidence that this
- has caused harm to those who provide care. The implementation has often resulted in a blame game causing damage that may be irreparable to once respected professions, facilities, and institutions. The doctor-patient relationship, trust
- has caused harm to those who take on the greatest challenges. The types of physicians, hospitals, clinics, practices, and institutions that care for the most complex and least advantaged patients are consistently rated lowest - because of the patients that come to them for care that no one else will provide.
- has caused harm to patients who still need basic access.
- has caused harm to primary care and to mental health with so much
- has caused harm to the scientific community
- has resulted in a less efficient and effective health care design with rapidly increasing cost of administration and measurement plus declining productivity of team members
Forced Failure of Productivity
Chaotic changes implemented before ready have been a poor fit. Forced sales of software not efficient or effective has allowed poor quality to be supported rather than poor quality technology allowed to decline because of poor fit or lesser productivity - a huge industry cost impacting all delivery team members forced to be less effective and more burned out.
James Cameron noted after 100 years about Titanic:
"Never have we been able to grasp the relationships between all the disparate pieces of wreckage. Never have we taken the full measure of what’s down there."
We should not wait another 20 years or double down on precision medicine. The results are very clear. Health care outcomes are about people changes, not digital changes.
More and more cost without quality improvement is the opposite of value and results in unnecessary diversions of team members from delivering care.