John Stewart Don't Know Squat About Data

This past Wednesday (Mar 27, 2013), the Daily Show included a segment on the backlogs within the VA and found the cause to be

• The reliance on paper to transfer medical records between the DoD and the VA

So far, so good. Good investigative reporting. If they had only left it at that and allowed viewers to form their own conclusions...

Instead, John Stewart made a joke about validating his preconceived ideas concerning Republican responsibility. He played a clip of a Republican member of the Defense Appropriations committe comparing AHLTA (the DoD healthcare information system) and VistA (the VA's Healthcare Information umbrella) to Play Station and X-Box which, though both can use the same TV, cannot talk to one another. AND THEN Mr.Stewart suggested that the parent of the household, if he/she wanted to minimize contention and confusion, could impose a single solution on the household. A photo of President Obama was displayed during this, clearly indicating that all the blame could be laid at the President's feet.

Nothing could be further from the truth. The VA has been assembling the components of VistA since 1987 and it was fully formed by the late 1990s. AHLTA was introduced amidst much fanfare at the beginning of 2004. The birthing process for AHLTA overlapped the adolescence and maturation of VistA, indicating a conscious decision (pre-2004) by the DoD to ignore the VA's efforts.

This entire mess is too complex in its origins and effects to discuss in a single blog entry so I'll content myself with one last piece of exculpatory evidence on behalf of anyone who has assumed elected office since 2004. The only way to move information from AHLTA to VistA is

1. Generate paper from AHLTA
2. Send the paper to the VA
3. Enter the information from the paper into VistA

This is also the reason why the DoD can't simply replace AHLTA with VistA.

There is a lot more to be said on this subject but, among other things, it seems clear that this is but one (albeit very painful) example of the inability of our health care "system" to adopt anything approaching a standardized view of the enterprise. Interoperability is something to be wished for but which cannot exist in an environment in which healthcare systems vendors are the X-Box, the Play Station, and Wii.

"Our Patients" as Rationale

Recently, the CEO of The Mayo Clinic, based in Rochester, MN, was interviewed regarding healthcare costs.  Read the interview at http://au.finance.yahoo.com/news/mayo-clinic-ceo-heres-why-155300485.html.

I worked at the Mayo Clinic in Rochester for 8 years so I still pay attention when Mayo speaks.  As I read the interview, two thoughts kept changing places in my mind.

"That's true." and "So what?" 

You'll note that "the needs of our patients" combined with "We've been doing this for a long time." are offered as the sole justification for any decisions made with respect to costs.  Without in any way detracting from the accomplishments and traditions of Mayo and not seeking to damage the esteem in which the Mayo name is held throughout the world, we need better justification and we need data.

It has been noted frequently that "I'm a doctor.  I know what's best for you." is a common attitude in the exam room.  Younger physicians are being educated away from that attitude but it is true that any physician knows a lot more about manipulating the human organism than the typical patient.  You can also see that the veneer of reeducation is quite thin if you venture to disagree with your physician about your diagnosis or treatment.

Well, that's the way it is and I'm willing to tolerate it when I'm sick.  That's medicine though and in medicine arrogance is treated as a fact of life and even valued.  In business and in fiscal policy, though, arrogance is non-productive and even counter-productive.

"The needs of my/our patients" is a greatest common denominator approach that guarantees the highest possible costs.  In a closed system (a specific clinic for example), an individual physician may be required to justify a particular therapy to a committee (for example, a transplant committee) and, in fact, the therapy may be denied even though it clearly is in the best interests of a particular patient.  When it comes to expenditures, however, there may be no scientific basis for decisions or, if there is, it is science mis-applied.  One of the most often heard arguments for an expenditure is that "everyone else is getting this."

My mother never accepted that as a valid reason but it is very often good enough for the board to approve expenditures of tens of millions of dollars.  Even that wouldn't be so bad, but the followup on those expenditures is woefully inadequate.  One thing I have observed in 13 years in healthcare is that no one ever looks back from a decision to spend money.  "I don't want to look at this too closely or my decision may be next under the microscope."

Medicine and healthcare are two different things entirely.  The system of healthcare in the US is terminally flawed and to the extent that it influences Medicine, the practice of medicine is as well.  Ask yourself how many of your healthcare dollars go into perpetuating the system rather than into preventing illness.  I don't have the numbers, but a comparison of dollars spent on basic medical research with dollars spent on lobbying and publicity would probably be too frightening for publication.

Healthcare Prices

The 36-page article in the current Time magazine has generated a lot of buzz.  The author/reporter has appeared on many TV venues already.  His states that "Question 1 has never been asked." where Q1 is "Why are prices so high?" and Q2 is "How will the costs be paid?"

I have spent nearly 13 years inside healthcare.  By the way, when I use the term health care (two words) I am referring to the medical side and when I use healthcare I refer to the business which includes vendors of supplies, technology and services as well as the non-medical aspects of clinics and hospitals.  Q1 has been asked repeatedly but never in a national forum such as Time.  The response is and has been the same.  You get shuffling, arm-waving and redirection.  What you never get is an answer.

In a way this is similar to recent revelations about certain banks who have laundered drug money, facilitated illegal transactions in violation of US and UN sanctions and provided consulting services to sanctioned nations on how to circumvent sanctions.  Caught with blood on their hands, they are unrepentant and simply threaten dire consequences if they are prosecuted or held to account.

"We're working for the good of our patients!" is part of every response from healthcare.  In fact this shibboleth is a mutation of both the Hippocratic Oath and the motto of the Mayo Clinic.  In a discussion during the formative years of the Mayo Clinic there was discussion about which of two paths should be taken and the response from one of the brothers Mayo was, "The needs of the patient are the only needs to be considered."

This is clearly in alignment with the Hippocratic Oath and the practice of Medicine.  Questions and answers are clear cut when the patient in the exam room or on the operating table is in focus.  When "the Patient" becomes "our patients" the focus is no longer so clear and both questions and answers get fluffy.  Healthcare has been allowed to cover itself with the very porous shield of "our patients" for far too long. 

There is massive collusion in every aspect of the healthcare vertical.  Prices everywhere are based on what the customer will pay and cost never enters into the equation.  No one is interested in cost including the payer with one exception--Medicare.  In fairness, the fear of litigation drives up costs but since costs are not the basis of price in healthcare except as a very insignificant seed around which is wrapped layers and layers of dough, this fear can hardly be used as justification.

Lowest price is recognized as a negative since customers immediately wonder what they're NOT getting.  Are the manufacturing processes not controlled?  Is contamination going to be a problem?  Utility and usability, even applicability are given lip service in the buying process but the business always goes to customer service which, in healthcare, is frequently in the form of high-priced consulting services anchored by high-priced account executives.  I have personally participated in several purchasing efforts which were identical to one another in terms of process and result.  The process, based on carefully researched industry best practice (strangely enough, defined by the vendors), includes

• forming a team of stakeholders
• creating an RFP (Request for Proposal)
• researching likely vendors (you can't just broadcast an RFP and wait for responses)
• submitting your RFP to the list of selected vendors
• sitting through demonstrations and presentations by each vendor (none ever declines to participate)
• comparing all of the proposals to that of our "favorite" vendor
• awarding the contract to the favorite
• signing an ancillary contract for "support services" whose cost, though large, is never included with the purchase price.
• forming an implementation team
• "partnering" with the vendor's implementation specialists on a multiple-month (or year) project to put the system of product into service for "our patients"

The only way to have longevity in healthcare is to buy into this alternate reality and act as though what you're doing makes perfect sense.  If you aren't able to do that, you may as well look for other employment because you will live a life of frustration.

This is why it looks as though no one ever asks Q1.  The only entity that could ask and demand a real answer is the government and that isn't going to be allowed.

Take Control, Patients!

It's long past time that patients demonstrated some impatience over their treatment by healthcare providers.

Let's be clear. I'm not talking about diagnosis and treatment necessarily. Those can actually be accomplished without any patient at all and they routine are. All they require is some symptoms.

Of course the symptoms must be attached to a means of monetary compensation--hence the need for a patient.

I had spent the past 25 years in Minnesota prior to coming to central Ohio in 2009. During that time I lived in the Rochester area and worked at the Mayo Clinic and the area's only alternative, OMC. In all of that time I failed to appreciate just how unique and effective the healthcare "system" was. The contrast upon arriving in central Ohio and seeking a primary physician (my doctor) was breathtaking.

The concept of a group practice was defined by the Mayo Brothers during the early part of the 20th century. In that model, the patient of one was the patient of all in the group and a single chart (and charting system) was accessible to and used by all as a condition of becoming a member of the group. Here, although the term is used, it refers only to the use of a common facility and the sharing of diagnostic and therapeutic equipment. Patients and their charts belong to one and only one physician within the group. No common system of charting is apparent and another physician--even one within the group--may find it difficult or even impossible to locate specific and critical information in the chart.

There appears to be no such thing as a multi-specialty group so that I am forced to consult several different physicians in different groups in order to have my health needs addressed. What I have seen is that this represent a significant risk to me since each of those physicians has only a fragment of me. This means that I must know enough about medicine to protect myself from mistakes about to be made. I never intended to be a doctor and I resent having to pay large sums for diagnosis and treatments which, without my active participation, have a high risk of actually doing me harm.

I'm interested in your point of view and will post it here. I plan to conduct surveys and post the results and analysis.