Health Care: providers are more important than patients

Bear with me, I am not a very good writer. But I am teachable so will hopefully improve as I do more writing.

Health care is a multi-faceted, complex space. It has been getting a lot more attention of late and from some very important people I might add. This is all good. The more people engaged in the issues of health care the better.

However, I want to mention one really important caveat. Providers need to be the center of attention when it comes to fixing health care. Not patients! I know (if anyone reads this) the likely readers of this blog will be patient-centric folks. And I also know that those words just written are anathema to them. Good. I want people to think and think very hard about the trajectory of reforms, changes, fixes and course corrections in health care. I will explain my rationale too.

Disclaimer:
Let me be clear, nothing about the broad descriptions of providers and health care should be construed as an attempt by me to glorify them or deny the reality that there are glaring issues, problems and failures in health care and that providers are in part to blame.

For starters, providers have all been patients but patients have not all been providers. Why should that matter? Perspective matters. Maybe kind of like @msuster. He has been on "Both Sides of the Table" in the VC world and it gives him a better perspective. I'll concede that this might be a minor point. But worth making.

Here's a major point, to me anyway. All providers have a duty from a combination of moral, ethical and legal confines to make the patients for whom they care the center and primary focus of their lifes work. Many also have an intrinsic, life-calling, mission to care for patients as well. I have had countless encounters with "newbies" in health care who tell me they are pursuing their career because, "I want to help people." This is something that is found in few other places and cannot be minimized in the least. Okay, addendum to disclaimer, I know there are providers who operate under none of those constructs rather, for their own selfish ends. However, here, as an example of the norm, is a link to a video (http://bit.ly/uV5Akc), which is a little long, where you hear first hand from someone who chose to protect patient's interests to the peril of his own career, on more than one occasion. Yet, he ultimately became very successful (for himself and millions of patients around the world). It is a great lesson, for us all. Chose to do the right thing, always, and success will follow.

Another very important issue, the education infrastructure for providers in this country is second to none. There are hundreds of thousands of great professors, instructors and teachers who provide the educational backbone for the medical professionals coming into the market place. I can think of many in my education who were not only exceedingly bright but were dedicated and "called" to do what they were doing. These that make our educations fun and exciting are an incredible asset, ultimately to patients.

Similar to and part and parcel to the educational system is the research system in this country. Part of what prompted me to write this blog was the posts I get in my twitter feed from @Life_Sciences. I don't read all the articles. Who could? But I read most of their tweets. It is impressive, to say the least, the volume of research going on. Also impressive, the nuance and granularity of research going on. Here are a couple of titles for you, meant to impress:

Targeting PDGFR-β in Cholangiocarcinoma

Results of carbon ion radiotherapy for skin carcinomas in 45 patients

Immunohistological pointers to a possible role for excessive cathelicidin (LL-37) expression by apocrine sweat glands in the pathogenesis of hidradenitis suppurativa/acne inversa

These are just the last three tweets from @Life_Sciences

So what is my point in all this? How does this diatribe conclude to supplant the focus from patients to providers? Alas, I have to drone on a little more. I know we (providers) are the ones you (patients) see when your appointment time got screwed up, your lab results didn't get sent to the hospital in time for your surgery or you had to wait 2 hours past your scheduled procedure time. But we are not your enemy! I can't say that emphatically enough. And I know that you know that. However, there is a tone in the patient centered movement that puts us at odds with you. This should go away immediately. Emblematic of this were the comments I heard from the CEO of a startup EMR provider at the Health 2.o conference in San Fran last October. The gist was that no matter whether we (providers) liked it or not we were going to have to adopt the technology that was being given to us by companies like his (I graciously am omitting the name of this CEO and company). And I have heard variations of this theme my whole career, "whether you like it or not!" It is a dangerous and destructive mindset. And it is a big reason we are in the situation we are in. Providers are your allies. We dedicate our lives, many times in a meat-grinder of circumstances to learn how to give you good medical care. We are bright, educated, dedicated, disciplined and altruistic. Who would stay up 24, 36 or 48 hours in a row to learn how to be an engineer? But then when we need tools to do our jobs more efficiently, safely, humanely, mercifully... we are told, "you'll take this and use it no matter whether you like it." We don't like and resist adopting dumb, broken, old, ineffective, obstructive, (insert descriptor) technology, tools or processes. Suffice to say, for many reasons - which will be another post, there is a huge, gigantic, epic disconnect between those of us doing direct patient care and those building the tools of technology we need to help us do our jobs. I was at the Healthcamp conference prior to Health 2.0, the un-conference, where the participants could create the breakout session topics. I put up my little sign for a session titled, "Take your developer to work day" in order to help explain the divide between developers, hackers and coders with the providers. Result - insert audio of crickets chirping. Not to sound elite, rather realistic, too few know what we do, how we do it and why we do what we do. This is why I gave the background info of the life path, educational and research paradigms. Health care is a world unique to all others for many reasons. The players who have not been leveraged (sorry for the catchy and overused word) are providers! Quite the contrary. We are suffering from autonomy and calling deprivation. No profession with the background of training and dedication has been leaned on as much as health care providers. We have some of the worst systems in which to do our jobs yet still find ways to give excellent care to millions of patients, keeping them safe and helping them get well. Sure there are problems (more disclaimer) and those are all well known - thanks a lot Michael Moore. By the way, when was the last time Michael Moore was healthy? I'll buy you a treadmill and a copy of "The 30 minute Vegan" cookbook and trade you that for your health insurance - but I digress, yet another post to write.

I emailed Fred Wilson, after his post about health care. I told him an analogy a colleague of mine recently used with a patient of his. We (providers) are taking care of sick patients, most of whom are suffering diseases from lifestyle choices (still another post topic) in a broken system. Yet we are responsible for an exponentially increasing complexity of knowledge and are expected to do our jobs flawlessly. It is like asking a pilot (the patient to whom my colleague was speaking) to fly a broken plane. The pilot would never do that. The system is broken, patients are broken and we have to fix them in a snapshot of time. Where's the sense in that?

Engage providers with real tools that work. Tools that don't become an end unto themselves - i.e. Government mandates, core measures, JCAHO accreditation, CMS guidelines, ICD-10, EMRs of all varieties, etc. Use the same business model of the current raging, hot fire of social networks - users (providers) are the value! I have said this before (no offense to Foursquare) and will say it again. It may be cool to be the mayor of a Starbucks in Palo Alto but having cancer sucks. If you understand the background of why that statement resonates then you are starting to understand the world we live in. There is technology out there that makes what we use in our daily lives seem laughable. It would be like playing pong next to someone playing Call of Duty on the PS3. I am not exaggerating. If you think I am then come with me to work some day. I will make that happen tomorrow!

Providers should be the primary focus in anyone's thesis for how to engage in the health care space. If we have help in improving the way we do what we do then you (patients) will directly benefit. You will get what you want - better care, cheaper price tag! To me, it's a no brainer!

How About Both Sides of This Table?

@msuster is a steady source of good info in my Twitter feed. His recent tweet with reference to a blog post about the purchase of Health Data Insights is fantastic news for him and his firm, http://t.co/Z0UJMdwl. I wasn't familiar with HDI so I read a little about them. It's fantastic that technology is rooting out fraud. As a taxpayer I couldn't be more happy. But there is another side to this coin. I don't know what the data is but I know there is a percentage of "fraud" cases in medicare and medicaid that are simply because providers, or their staff, incorrectly code or bill for the services actually rendered. The billing codes for procedures are very precise but procedures are not always very precise. Additionally, there are many other points at which a claim could be labeled fraudulent. If, for instance, an incorrect time, date, patient demographic, diagnosis code (there are about 30K diagnosis codes, soon to be over 130K codes with the implementation of ICD-10) or other important information is incorrectly entered into a claim form it could be considered fraud. The process to resubmit, sometimes multiple times, in order to correct a denied claim takes a lot of time from staff and adds cost to the system when in fact services to a patient were actually rendered correctly. I know there are two different things I am referencing here, incorrectly filed claims and fraud, but there is some overlap as I alluded to and admit that I don't have that data at hand.

In the private insurance world the billing process takes on some interesting twists and turns. The group with which I work was not paid for a single claim for months until each claim was resubmitted.. This was from the main insurance company we deal with (and with whom we have a contract). And the claims were submitted as our office staff has always done, for the last 20 or so years that the group and office manager have been in existence. My theory, pessimistic, is that insurance companies know a certain number of claims will disappear in this submission and re-submission process. It helps their bottom line while it hurts my groups' bottom line in two ways. First, we may forget to refile some of those claims and second, it takes more staff or hours of paid time from that staff to resubmit al those claims. You all can come up with a number of reasons from a non-pessimistic perspective why these kind of things occur. Maybe the truth is somewhere between.

Suffice to say though, the medical claim process is a huge pain point and ripe for innovation. There are some companies getting into this on the periphery (Simplee Health comes to mind) and of course HDI on the payer side. But few technological advancements are being made that help providers. Sure there are EMR and medical practice software providers who provide and electronic platform to enter the same data. But more is needed than a simple digital version of what we have always done.

Here are few questions for the tech folks brighter than me to help and answer/solve. Where are the algorithms on the provider side that recognize trends or at the very least gives cues for complex billing situations, or just cues to include all the pertinent data? Why doesn't billing software submit claims automatically to payers instead of having to go through a clearing house. Clearing houses are these entities which have grown up because billing software providers can't/won't integrate the idiosyncrasies of claim forms from all 1100 or so payers that exist in the U.S. and I don't think anyone in this industry has ever heard of and API. I contacted our practice management/billing software provider so our group could build its own app to get case and care data to our office via that app. Me: "Can I have your API?" them: "We don't have an API." Me: "So can I send digital data about anesthetic cases to our billing software?" Them: "config.sis, MS-DOS, $$$$$, archaic, re-invent the wheel, blah blah blah" (I paraphrased them).

Once again, I admittedly lack data, but extrapolate from the huge dollar amounts in @msusters post and know that the correlary situation occurs on the provider side. It is a maddening source of frustration for providers (good ones, not the tools that are really bilking the Feds) and our staff members. This is a pandemic across the U.S. so anyone who would like to solve some of these issues will probably get bought up for multitude millions! Good luck!

Collaborative Health Record

Collaborative Health Record, CHR! Forget about the EMR, EHR, PHR. This is what is needed to change the landscape of health care, for good (double entendre)! Providers and patients need to connect in the context of the actual patient record.

I am just putting it out there so that I can be the first to come up with a new term. Unless, of course, someone else already has.

More later...

Simplee

I recently came across a new company called Simplee (http://simplee.com). It is a site that you can sign up with for free and link your health insurance account to in order to track, organize and manage your health care costs. Although those are wonderful reasons for anyone to use Simplee, the real value is going to come through all the data they are gathering as a by product of their stated goals and use cases.

In short order, Simplee will be able to tell what the contract rates for all procedures and services for each provider and any given insurance company. That is huge. But that information is proprietary, according to the insurance companies and the providers. I am not sure if this will result in a legal battle if they attempt to make that information public. It seems that, although private, the information should be able to be shared openly by individuals, which is Simplee's model. Each person allows Simplee to have access to their online health insurance account. By doing so, the individual allows Simplee access to their explanation of benefits (EOB) forms. These forms are required to be given each patient, by law, from the insurance companies. So, how can information given to the public be proprietary. Legal fight?

The bottom line is this. If light is shed on who pays who how much, then hospitals can't leverage against insurance companies for exorbitant rates of pay and vice versa. Procedure rates vary wildly from hospital to hospital even within the same town. How and why this happens is a mystery hidden behind that proprietary veil.

The ePatient community should jump on this opportunity like a swarm of bees. It can be a huge avenue for cost containment in health care.

Another company, Castlight Health, is trying to do a similar thing. Yet I do not know how they are going about gathering their data.

I must confess though, this post was hard to put out there. I had this idea to "crowdsource" cost data from EOBs months ago and could not ever get it off the ground. Simplee has taken the same idea and done one better with their model. I hope they have more than a wildly successful company. It will definitely disrupt.

Traitwise.com Launch at Health 2.0 Conference

The Health 2.0 conference in San Francisco last week was a great event. It is nice to see such attention being paid to the area of technology in health care. There were a lot of neat people and companies who participated. One in particular garnered the most interest from me. Trait Wise was one of the 10 companies choosing the Health 2.0 conference to launch their site. It is a fantastic concept and deserves our participation. If Trait Wise (www.traitwise.com) is successful the payoff will be greater than any of the other companies and concepts at Health 2.0. That is a rather bold statement but I will hopefully substantiate the assertion.

Reliable data about the infinite variables effecting our health has been impossible to produce. That's hopefully the past. Trait Wise is attempting to crowd source what they call the "phenotype" data of the human condition. "By 'phenotype' we mean all the aspects of the human condition that are not chemical -- the reactions to treatments, the feelings, emotions, actions, attitudes, and the environment, to name a few," to quote their website. By inviting participation from health care and the population at large they are hoping to build a database, which will reveal correlations, trends or other observations. This data can point the way for scientific research in order to bring personalized medicine into reality. Participants are encouraged to answer large numbers of questions and to generate questions. Instead of a select, minority of scientists bearing the burden of observing trends, the world's populace can participate. Then let the computers process the data.

As a health care provider (nurse anesthetist) who is not in an academic center, I have limited ability to spur research. Although, I have encountered thousands of patients over 24 years in health care, many of whom have caused me to have questions in my own mind. I have often wondered what variables in patients' lives have brought them to the state of health wherein I encountered them. Why does one person live a healthy life into their 90s and another not? What are the behaviors that will make me most healthy? We know some of the macro answers to those questions, like don't smoke, don't stress, eat lots of whole grains and vegetables and so on. But we don't know the personal, individual answers and until recently, we had little hope of ever knowing.

Creating a database of myriad questions, which myriad people need to answer, is the start of a great process whereby personal, individual medicine is possible. Once the database achieves significant power (let the statisticians figure those numbers out) then trends and correlations can be compared to genotype information. The genome and epigenome will point to many more cures than pharmaceutical R&D ever has. If an individual or group of individuals are known to be at risk for renal carcinoma, then there is likely some "phenotype" data to help them make choices to minimize the risk or avoid the cancer altogether. Basically, instead of being confused by the onslaught of consumer health information (e.g. one article says coffee is good for you and another says coffee is not good for you) this kind of database has the potential to let the individual know if coffee is good for that one person. All health data has to eventually be that personal and granular.

We have upwards of 80,000 chemicals in existence in the U.S. There are almost an infinite number of molecules in the food and beverages we consume. We make choices every day about life that also could lead us in an infinite number of directions. It is worth starting the process of revealing how all of those variables impact us. It is worth making sure we have the freedom that comes with knowledge specific to the individual. It is worth answering all the questions. It is worth asking all the questions. If we don't, we give up our freedom by omission and should take what comes our way with resignation.

Technology in Health Care

Bad is the standard in health care technology. That is for certain. I am referring to the technology of data management, workflow solutions, provider networking, etc. Why is this so? There are a lot of reasons. But the one I would like to highlight in this post is the lack of good techies in health care. Let me explain and address the technorati as well.

Most of the cool tech tools and apps are coming from programmers and developers who see a problem or opportunity then set about solving or seizing. Not so in health care. Very few involved in direct patient care (where we desperately need current tech deployed) can write the lines of code, design UIs or do anything closely resembling the skills required to bring this needed tech to fruition. We (providers) are really good at health care, which you should be as stoked about as we are about kickstands on the Evo, credit card payments on your iPhone, the Starwalk app, Twitter, Google and so forth. We are not good at design, develop, deploy for stuff that we really need.

Buried within the situation I just described is the enormous complexity of the health care system. It is not an environment given to innovation, which can be quickly brought to the deploy phase. There are significant considerations not important to the general tech community. And I have come to believe that the best and brightest developers, programmers, entrepreneurs and VCs flee from this space like it is the Black Plague of death. But here is something the technorati all-stars need to realize, if you neglect this space YOU will pay for it personally and likely, deeply regret the neglect. I am completely confident in that statement, not because I am a prophet, rather because I know everyone on earth occupies a body which will at some point in time need health care. I see it everyday, suffering, pain, confusion, sadness, despair. These are not descriptors of the rare encounter with patients nor is it usual to certain populations. If you are 23 and healthy you have a legitimate reason for a big disconnect in what I am saying. But most people never tune into their health until it is too late. We need the tools of technology to help us help us all be healthy.

Typically we see giant projects deploying legacy software at huge cost with little ability to respond quickly to users ( patients and providers) needs. We need agile development with resonable costs. We need apps that work. We need UIs that either look like what we are used to or are such design miracles that we don't need hours of training to figure out how to use them. We need ways to gather the enormous amount of data that is generated during patient/provider interactions. We need good ways for patients to access their providers. We need good ways for providers to access each other. I could keep going, but I think you get the point.

What I am trying to do is light a fire that will cause some serious disruption in health care. There are some very exciting discoveries, which will have huge potential impacts on our health. We need good technology to help us. My personal favorite area of promise is epigenetics. If we only had good ways to collect massive amounts of data about us and our behaviors. Then we could make some serious headway in this promising field.

That's it. We need your help. It's cool to be the mayor of Starbucks in Palo Alto. But it really sucks to have cancer! Think about that for a while.

Health Provider Quality

In the course of my 20+ years in health care, there have been times when I have had to cringe at the low quality care being given by a particular provider. It is a helpless feeling. For patients, I think there is an assumption that all providers are created equally. Or, in other words, if someone has the license as a medical doctor, nurse, physicians assistant, etc., then they have to be a good provider. Not true. And there is no credible way for the public to determine the quality (or lack of quality) any given provider brings to the table.

Certainly, one can perform an online search to see if their provider has been disciplined by his/her state licensing agency. Often, this data is state specific and doesn't include data from other states. It is possible for a provider to hop from state to state to try and avoid losing a license or avoid disciplinary action.

By and large, all those who practice with a valid license for their vocations are competent and provide adequate care. But the real data, patient outcomes, is like a vapor. It is not gathered, in most instances, and is far from being subjected to good analysis. To be sure (as if we all didn't know this) outcomes matter. And sometimes the least noticeable practice decisions can have the biggest impact. There is a massive, disjointed effort underway to gather more data with the implementation of electronic medical records. Most that I have seen, or am aware of, track what they are told to track. This mostly includes markers of "evidence-based medicine" and check box care. Care sometimes devolves into a cookie cutter routine. This "dumbs down" provider practice instead of elevating it, in my opinion. Most patients fall in the big fat part of the bell curve and do well with this kind of practice. But not every patient or every problem the patient has, fits nicely into this context. Additionally, evidence-based medicine is tenuous at best. There are myriad ways to contaminate data and recently there have even been allegations of outright fraud in establishing best practices (to wit Dr. Scott Reuben).

I think, in some ways, check box, evidence-based medicine protects the sub-par practitioners. Alas, the issue of unknown provider skill and competence level will continue to be a problem until we are able to establish good ways to track patient outcomes.