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Saturday, July 23, 2016

The Health Care Productivity Treadmill

Recently at THCB:
How would you react if you sent your sputtering car to the auto mechanic, and they stopped trying to diagnose the problem after 15 minutes? You would probably revolt if they told you that your time was up and gave back the keys.

Yet in medicine, it’s common for practices to schedule patient visits in 15-minute increments — often for established patients with less complex needs. Physicians face pressure to mind the clock while they examine you.

That’s not to say that your physician “clocks out” as soon as your 1 p.m. appointment hits 1:15, or that all appointments last that long. What it does mean is that patients and doctors may be deprived of the opportunity for more meaningful discussions about the underlying causes of their problems and plans to improve them. A woman in her 50s who presents with high blood pressure and obesity might need medicine. But a longer conversation about the stresses of being the primary caregiver to her father, who has Alzheimer’s, could help provide strategies to help her look after herself.

When you see a new patient every quarter hour, there is often scant time to get to these root causes, to make accurate diagnoses, and develop the best treatment plans. And there is the danger that you miss a major diagnosis altogether.

The 15-minute appointment arose not out of evidence that it improves patient outcomes but out of production pressures — both the need to meet patient demand and to see enough patients to stay profitable...
By Peter Provonost, MD, "A Novel Proposal: Let’s Trust Our Doctors."
"See enough patients to stay profitable."
So, roughly 30 patients a day, give or take, say, 5 days a week, 48 weeks of the year (assuming closed days for holidays and other time out of the office). Take some current Medicare Fee Schedule data ("992xx") and do some math.

(Click to enlarge. The rightmost yellow column are 2016 payment data, vs the 2015 dollars to their right. I, for example, am a "99213," a Moderately Complex Established Pt.)
Then, consider some workflow throughput numbers, those simply pertaining to patient visit data acquisition, entry, update, review, and assessment (spanning the administrative to the clinical).
  • Admin/Insurance/Demographic
  • Chief Complaint(s)
  • Active Problem List
  • Active Rx List
  • Family Hx
  • Social Hx
  • Past Medical Hx
  • Past Surgical Hx
  • Vitals
  • HPI
  • ROS
  • Labs/Imaging
All the stuff that goes into the SOAP. Just to cite the two most common lab orders, a blood panel alone can have up to 80 or so parameters (my last one listed 31). A "UA" (urinalysis panel) may have as many or more. The "data" comprising each result will have an alphanumeric text name, numerical (or qualitative) finding, and a reference range (four actual data elements per "datum"). ROS ("Review of Systems") can contain up to about 122 data elements.

Then you might have to review priors as well, to estimate trends/progress ("flow sheet" stuff, "progress note" narratives).

Also, don't forget specialist consulting "impression" reports (e.g., imaging, or specialty things like my prostate tumor "OncoType dx" assay last year).

So, assuming all of the foregoing, and further assuming that your patient complexity distribution and "payor mix" gets you an average, say, $90 a visit, you might work you tail off to gross $650k a year -- before the myriad expenses (you can readily spreadsheet all of this; I've done it many times).
I might note as well that I've never gotten 15 minutes per visit with my doc. Back when I was with the Meaningful Use REC I'd stopwatch my personal visits, trying to gauge the overall workflow (my doc was also one of my MU clients). My face time with my PCP was typically 5-10 minutes of the entire encounter span.
(Click to enlarge)

I did have one PCP encounter wherein I got 13 minutes of face time with my doc. It was back in June, 2010, a month after I launched this blog.

Not being privy to their EHR scheduling module, I have no idea what time span was allotted for my appointment. Nonetheless, I spent 31 of the 50 minutes I was there (62%) twiddling my thumbs. I quickly learned to schedule my visits for early in the mornings, because my doc would always quickly fall behind schedule.

No wonder solo doc PCPs are becoming a thing of the past. See my prior post "Clinician burnout."

Interesting comment beneath the THCB post:
The rapid fire care that patients and physicians despise alike has been generated and reinforced by the corrupt, AMA endorsed Relative Value system. Regardless of if I treat 1 problem or 10 problems, the cognitive effort of physicians is reduced to “office visit”. Hence the inability to adequately dedicate time appropriately for patient care. Fee for service is not a bad idea when you actually recognize services as problems addressed or solved, rather that those procedures that are exalted by some chosen few. No one wants their surgeon rushing through their surgery. Why is rushing through office visits tolerated by anyone? This question needs to be directly addressed by those doing the price fixing in medicine. Then explain why Primary Care should not exit the system and actually serve patients they way they deserve for an appropriate price. - Leo Holm, MD
None of this is actually news. I've been hearing these criticisms and complaints since I started with the "DOQ-IT" initiative in 2005. The irreducibly high cognitive burden patient visit environment remains. It is simply not reasonable to expect clinicians to perform recurrent daily data-heavy glancing process "drive-bys" within highly complex health IT systems (too frequently addled by poor UX) in compressed time frames and routinely arrive at accurate dx's.

There's also Margalit's nagging question: Are structured data the enemy of health care quality?

Will any of these concerns get any Presidential campaign attention?

Asked and answered, 'eh? It'll all just be about the money, and access to the system (not to imply that those are not fundamental issues; the best clinical infrastructure in the world is irrelevant if a huge proportion of patients are locked out or bankrupted owing to cost).


apropos of the foregoing, a new book has come to my attention.

...As a complexity scientist, I spend a lot of time being preoccupied with the rapidly increasing complexity of our world. I’ve noticed that when faced with such massive complexity, we tend to respond at one of two extremes: either with fear in the face of the unknown, or with a reverential and unquestioning approach to technology.

Fear is a natural response, given how often we are confronted with articles on such topics as the threat of killer machines, the dawn of superintelligent computers with powers far beyond our ken, or the question of whether we can program self-driving cars to avoid hitting jaywalkers.

Even if we aren’t afraid of our technological systems, many of us still maintain an attitude of distaste toward technology. We see this in our responses to the inscrutable recommendations of an Amazon or a Netflix. Many of us even rail at the choices an application makes when it tells us the “best” route from one location to another.

On the other hand, some of us veer to the opposite extreme: an undue veneration of our technology. When something is so complicated that its behavior feels magical, we end up resorting to the terminology and solemnity of religion. When we delight at Google’s brain and its anticipation of our needs and queries, when we delicately caress the newest Apple gadget, or when we visit a massive data center and it stirs something in the heart similar to stepping into a cathedral, we are tending toward this reverence.

However, neither of these responses—whether from experts or laypeople—is good or productive. One leaves us with a crippling fear and the other with a worshipful awe of systems that are far from meriting unquestioning wonder. Both prevent us from confronting our technological systems as they actually are. Next time, the results of our failure to understand might not be as trivial as a frustrated Wall Street Journal reader being unable to access an article at the time of her choosing. The glitches could be in the power grid, in banking systems, or even in our medical technologies, and they will not go away on their own. We ignore them at our peril...
I was alerted to this over at The Daily Beast, "Tech's Not Our God. Or Our Devil." The foregoing is verbatim to that found in the Amazon "Look Inside" larger excerpt.

Resonates with stuff in my prior posts such as "Evolution, science, technology (including Health IT), and the future of cognition," "Convergence: the future of health," and "Technology, particularly the technology of knowledge, shapes our thought," to cite just a few.

See also "The future of health care? "Flawlessly run by AI-enabled robots, and 'essentially' free?"

More to come...

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