Time to Burst the HITECH Bubble

Since 1999 the United States has been led on a wild chase to pursue ever more costly solutions for "medical errors." Ever greater promises have been made since To Err is Human regarding the ability of technologies to Cross the Quality Chasm. Hundreds of thousands of lives each year were supposed to be saved. Year after year the nation awaits change. Health spending has more than doubled from 1.3 to 3 trillion dollars. In recent years administrative and non-delivery costs have accelerated.

It is time to burst this wasteful and distracting bubble.

We have been through enough boom and bust cycles to see that all newly develop technologies have consequences as they are implemented widely. The technologies can be applied safely with proper attention to the limitations. The limitations are often not fully known - in the technology or in the people impacted. In the case of health care the limitations of technology are significant in areas such as cost, productivity, and distraction from care delivery. Those developing the technology and promoting it are far beyond the limitations.

“The Titanic disaster was the bursting of a bubble.” 

The HiTech Bubble is also primed for a fall. 

This is not about going backward or away from technology. This is about:
  • A return to evidence basis 
  • A return to truly accountable care rather than speculation
  • A return to efficient and effective health care
  • A return to focus on the process of delivering health care
  • A return to Do No Harm 
Technologies applied to health care have limitations regardless of use by surgeons, accountants, CEOs, nurses, lab techs, patients, or health policists.

Hypocrisy vs Hippocratic Oath

Physicians are held to high standards for very good reasons. Researchers have human subject research standards. Somehow those who impact health care and humans, have managed to avoid the necessary scrutiny. They were accelerated into action in health care, but they were not given a crash course in Do No Harm.

Designers of systems, practices, state health care, or the care of 330 million should at be held accountable to the same standards as with those delivering health care. In many ways the standards should be higher as those who can be damaged are multiplied far beyond the ability of individual team members.

With careful reflection you will understand why the complex process known as United States health care delivery needs different direction. Engineers come closest to understanding workforce, budgets, product, productivity, management, and other aspects of coordinating a process for efficient and effective outcomes.Turning the reins over to innovators, entrepreneurs, and researchers has been ill-advised. Disruptive influences must be held to the same standards as standard methods of delivery.

The fact of the matter is that health care is constantly changing as people and technologies change. New ideas and technologies must be put into action. But balance must be maintained. Paying so much more for technology and depending so much on untested and experimental applications has created more problems than benefits.

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 Aligning Forces for Quality (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. 

It should not be a surprise that there were not significant changes. This was likely because there were no changes in the population or as suggested, all populations (study or control) were changing the same. The intervention did not work for the main purpose. There was success in consumer focus, but not in population health or changes in health care quality measures.

It is a great complement at this time in history for RWJF to report no difference. RWJF has demonstrated integrity in this reporting. The pressures to report significant findings must have been enormous after so much time, talent, and treasure. The finding of no improvement in the main outcome may not seem like much but it is unprecedented across other foundations, associations, and government that have spent so much for so little return.

A return to objectivity and critique is needed if health care
is to be guided and returned to care delivery focus.

Time to End the Era and Error of Medical Error Focus

Regression equations led to medical error focus. All it takes for regression research is to load in variables that you think apply to demonstrate medical error (or insurance coverage). There are many variables available that are convenient to load. Unfortunately not enough variables are known and even less are loaded. If the perspective of the researcher is limited to clinical intervention focus, there may be very little loaded about patient, local resource, community, or other factors.

The most important variables involve actual patients. Key social determinant variables and other determinants are not known or are approximated. Critical need to know information was missing - helping to launch the focus on information. One reason for race or ethnicity to look impressive as shaping outcomes, is the fact that race and ethnicity are the only individual factors. This is particularly true in cancer variables regarding outcomes. Income or education or other variables are often assumed from the zip code or county of origin. When specific variables are missing, other variables look more important.

The last twenty years has focused on Big Data and more information and greater levels of processing, but the push this direction was a shot in the dark.

Health care quality has not improved despite hundreds of billions a year added for more technology, more subspecialized services, more subspecialized workforce, more cost control, more high risk patient monitoring, more high cost, more quality improvement, more digital and data compilations, and more clinical interventions. Government watchdogs have critiqued many of these as costing as much as the dollars saved, but even more is implemented.

We now spend thousands more each year per person for health care 
than we did just a few years ago for no improvement. 

This results in across the board cuts and greater focus upon cost cutting. But the bloated administration is not cut and neither are the high tech services - leaving the nation short on support for 60% of services and about the same proportion of the American people, if not more.

Failure of overall outcomes improvements should not be surprising since the outcomes are predominantly about people and not about clinical interventions. Because costs have increased and quality has not improved, the nation has moved to lower value - despite attempts at higher value and lower costs.

Value = Quality

The failure to control health care cost increases and the failure to control cost increases within health care, has marginalized the ability to deliver health care. 

Primary Care Medical Home costs $105,000 more per primary care physician with minimal if any gains (Annals FM). This negates at least 20% of the revenue generation and effort of each primary care physician and without change in outcomes. This also is the opposite of value.

Meaningful Use to MACRA has added tens of thousands more per team member per year in direct costs and creates more consequences. Quality metrics in theory is quite different compared to the reality of health care. Even in the rare instance when you can assign a provider to a patient to an outcome, the ability to discern a provider from the average is limited (as in 80% (very rare) cannot discern quality. The noise greater than the signal signifies failure by design. Even worse, the digital attempts to shape outcomes are clinically based - the interventions with the least influence upon outcomes.

Grandiose Eras Come Crashing Down

Grandiose claims have made it difficult to believe claims of any kind. Even if results look poor, adjustments can be made to obscure the obvious. Significant and relevant differences should not require manipulations.

Grandiose technological 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. New technologies shaving tiny units of time and small portions of percentage points have created vast disparities in small periods of time. The massive advances of technology have created numerous security, privacy, cost, and consequence issues - more than health care has even started to address.

Grandiose creations have resulted in the need for reforms and a return to relevance. Sometimes it takes a major event to find reality in the midst of greater fantasy, such as when Titanic ended up on the bottom of the sea.

James Cameron has spanned the heights and depths of this planet, and perhaps the heights and depths of humanity as well in his movies. He noted in National Geographic,

“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.”

The Titanic represented more than an unsinkable ship that sank.

Technology is only as good as its limitations

Architects and engineers have sometimes exceeded the limitations of technology, as seen in collapses of bridges and hotel structures. Thankfully the lessons were learned quickly. The failures lead to more restraint, more study, and better use of technology with necessary limitations.

Titanic killed hundreds via pick your choice of - full speed ahead, wrong turn, no need of safety devices, glancing blow rather than direct hit, one too many compartments flooded, calm moonless night without white breakers to see the bergs, inclusions in the rivets, poor understanding of inability to steer, failure to pay attention to iceberg warnings

But now we have developed massive capability to cause harm by diverting scarce resources to technology, by overcharging for technology, by using technology to regulate health care, by using technology to shrink spending or change provider behaviors, and by disabling those who understand the limitations of technology - those who deliver the care.

The Limitations in Health Care Have Been Neutralized: Full Speed Ahead

The accelerator pedal was applied and has been hammered down. Chaotic change has taken over. Physicians, nurses, and health care associations should be applying the brake pedal. Some have done so, but others have jumped on the accelerator. Some fail to take a stand, even when most of their members and patients are impacted.

Nurses have been marginalized since 1983 via DRG design. Physicians have been driven steadily out of independent practice by numerous design changes. Association leaders have been shaped by corporations, institutions, and dedication to activities outside of day to day practice. Presentations at conferences are dynamic, cutting edge, disruptive, and high tech.

Those who deliver the care and deal with the consequence are no longer in a position to shape care delivery. One clue to the sad and worsening situation is the constant call for coordination and integration - yet the next designs result in even more disconnect.

Physicians or nurses need not be in charge, but they must play a critical role. They could point out the lack of breakers on a windless night and the need to slow down. Nurses could indicate that there are not enough life vests. Researchers could point out that still waters often indicate iceberg fields ahead.

All who deliver care must learn what they know and what they do not know, what they can do and what they cannot do. Innovators, reorganizers, policists, cost cutters, CEOs, researchers, management consultants, and others that do not deliver care have very different agendas that are often quite different and that conflict with Do No Harm.

Alternative Agendas Accomplished also with Consequences

It is not hard to see the displacement of physicians as a goal of many different entities. The zeal to accomplish this has removed an important influence.  There are other consequences.

The damage to physicians may be irreparable. The medical error focus became prominent in the 1990s and resulted in To Err is Human in 1999. There has been little critique of the equations, the variables, the controls, or the lack of limitations. No one asked for alternative explanations for poor outcomes. No one considered people factors.

The studies arising from these equations and the very term "medical error" has resulted in blame and shame. Errors are made, especially in a profession where difficult decisions have to be made. But there is a vast difference between "medical error" and "doctor error." Patients and many in the media may not understand this difference. The impact upon the ability to trust physicians is clear to see.

Patients may or may not trust their physicians. Regardless of studies or stories in the media or social media or ratings, patients and families and physicians must work together for best care. Lack of trust can make this difficult or impossible. This is also not value from health care. Why Not Trust Our Doctors?

Year after year we spend more on health and get less. We have made more health care available to few with less available to most. The payment design has at least six degrees of discrimination preserving this disparity.

Polarizing the Nation and Progress

Beyond health care the impact is also significant. Health care has become so costly and polarizing that it distracts the nation and its leaders from needed changes. The cost has dwarfed key decisions across Congress and state legislatures. The impact involves day to day life for large segments of the US population in areas such as nutrition, housing, child development, social services, and support of seniors to stay in their homes. Much was given up for very little in the way of reform in health care.

As support for people shrinks, it is likely that outcomes will shrink in health, education, and other areas. Technology is shrinking support for people. People will have to realize this and fight back for any real improvements in outcomes.

As soon as 2025, it may well be understood that so much time and effort was spent on health care in the last decade, that little was accomplished 2010 to 2020. Some will blame Congress. Some will blame the President. Few will figure out that so much time and effort was spent to accomplish reforms of little consequence (insurance expansion, innovative payment), that much needed reforms such as payment reform for cognitive/office versus procedural/technical and distribution of payments vs increased concentrations never had a chance. Insurance expansions of lowest paying plans fail to truly support the health workforce where 40% of Americans reside in 2621 lowest concentration counties where concentrations of lowest paying plan patients are concentrated. Innovative payment plans that have attempted to change physician behaviors have failed to change quality and appear to have changed physician behavior the wrong direction.

At the current time, those who oppose 2010 reforms are considered to be anti-quality, politically motivated, or worse. Closer examination may reveal entirely different and most important reasons.

Where do we go from here?

Bad Choice 1 - Doubling Down on Clinical Intervention

There are distressingly worse outcomes for infants, mothers, and others left behind. Disparities are more evident even if few seem to pay attention. Widening disparities shape widening outcomes as societal failure is more obvious from the earliest months and years of life.

Decades of experience indicates that the designers will be doubling down promising improved health outcomes for infants and for mothers - except that they cannot predict who will die. Only improvements in the population can address infant mortality, maternal death, and longevity.

Our nation has doubled down too many times. Each time results in theft of the resources to improve children from the start and other best investments for best health, education, and other outcomes.

Doubling down is popular in political circles. CMS has doubled down on MACRA after admitting failure in previous versions.

Bad Choice 2 - Precision Medicine

New proposals plan to go deeper into the biomolecular level. Organ system then down to disease focus has apparently not been costly enough. A movement more distant from societal fabric and people interactions and changes in behaviors and situations and environments is exactly the wrong way to go to address cost, quality, and access.

The Moonshot dedicated to disease focus is also a bad idea. At least President Kennedy noted that it could not be accomplished without reining in the profiteers.

Ten Concern Areas for Populations Behind and their Providers

Enough is Enough!

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 then and is still not ready years later.

HITECH also boosted the careers of many individuals into positions of enormous influence - as seen in
  • CMS Director Dr. Andy Slavitt arising from Wharton and Harvard Business School and the innovation engine of United Health Care - Optum. 
  • Commonwealth Foundation President David Blumenthal MD shaped HITECH. It is easy to see the focus on insurance coverage and technology focus but difficult to see solutions for health access arising.
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.

More generations of leaders were shaped by different influences. The first generation of family medicine leaders were mostly focused upon practice. They were practical and effective in building family medicine up until 1980. The restoration of family medicine, family medicine training, and a build up to 3000 annual graduates occurred in a very short period of time. Since 1980 family medicine has been losing in political and health care influence and in financial design. Family physicians have declined in memberships and in retention within family medicine positions from over 95% family practice to less than 70%. There has been little attention to the payment designs that negate training interventions as they steal family physicians, health access, care where needed, and more and more of the precious time of family physicians.

How Much More Can Health Care Team Members Take? 

Nurses wade through piles of documentation. Physicians devote 2 hours to EHR for each hour of care delivery (Annals IM). 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 declines in health workforce productivity, declines in morale, accelerating burnout, and even greater distraction from delivering care. Movements the wrong directions in cost, quality, and access are difficult to understand.

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. Once corporations had the initial foot in the door to share in health care revenues, the door has been busted down along with critique. If you oppose this, you are painted
  • as against progress 
  • as part of the wrong political party
  • as against quality
  • and worse
What if we are for health access, against discrimination, against waste, against unethical experimentation, and against unscientific claims and policies.

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. As always the half-truths are the most difficult to address. Yes, there is a need for improvement. No, there is not a simple technologic approach.

The result has been chaos. 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. Getting down to the depths to see may be difficult, but the evidence is there.

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
Health care has always had been slower in the implementation of change. This is partly due to sheer size. Physicians and nurses also have relatively long careers. It is also due to the "Do No Harm" priority. Rapid implementation of technology linked to payment before a real evidence basis and with inadequate understanding of the consequences has been a bad idea.

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. The results are very clear. Health care outcomes are about people changes, not digital changes.

Resist the urge to move ever deeper in debt with precision medicine - a move beyond disease focus to molecules and more distractions from people focus and care delivery.

Accountable care is also this - More cost without quality improvement is the opposite of value and results in unnecessary diversions of team members from delivering care.

We need engineering focus to make health care efficient, effective, productive, and relevant to all or nearly all Americans. Researchers and innovators can contribute, but should never be in control.

The coalitions that are built need not be focused upon quality metrics or cost cutting. Most of all they need to be focused upon the delivery of care. If we fail to place this as the top priority, then we fail in health care.

More on Selling and Swelling a Bigger HiTech Bubble

Recent Posts and References

Six Degrees of Discrimination By Health Care Payment Design

Assertions that Small Practices Can Prosper Are Not Helpful

Recovering General Surgery Is Impossible

Primary Care Must Rise from the Ashes of the Last 20 Years

Patients Should Be Changed, Not Physicians - Physician Behavior has been changed  -  the wrong way

Revisiting Basic Health Access in a Land of Smoke and Mirrors

Time Talent and Treasure to Measure Is Not Quality

The Mess that is MACRA - Kip Sullivan at The Health Care Blog

Value Failure By Those Who Promote Value

Bundling or Bungling, Once Again Into the Fray

Solving Mental Health Takes More than Race and Place

No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.
Copyright 2016


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