SATimes, Vol.1 No.37 January 3-9, 2009: 2008 is on its way out and I will have to remind myself to fill the right date on my prescriptions. Apart from this nuance, nothing else will have changed in my world. Or yours. Let’s not therefore confuse motion of a clock’s hand with change. Looking in the rear view mirror, 2008 has been a year many of us would want to forget. That would actually be a tragedy. Because, it is a year we all need to remember. In it lies a lifetime of learning that we must absorb, lessons that validate what we South Asians all grew up with but thought less valuable in today’s Kalyug (Dark Ages).
2008’s typhoid tainted tomatoes brought to life verses in Manusmriti that implore us to wash hands before we touch food. Wall Street is not the only one that needs to take a cue from Jainism’s Ratnatreya (three gems): Bisphenol contamination in plastic baby bottles personify how following the principles of Right Vision, Right Knowledge and Right Conduct would have prevented us raising our children on toxic milk. It is not for nothing that our founding fathers built this great nation on principles, not rules! How we’ve deteriorated into a country that follows rules within its borders and breaks them beyond those boundaries! No surprise, then; that its citizenry in Board Rooms chose to behave so recklessly that my elderly patients now need notes for utility companies begging them to continue supplying electricity to their homes so that they may breathe life from their nebulizer and oxygen machines.
As we look at 2009, let’s use these principles to analyze the core of Obama’s prescription for health and score it:
1. Right vision:
The way it is now, I can't get access to my own patient's previous records when they end up in a hospital at midnight. The cardiac catheterization images were on an older type of machine that is no longer supported. Older records were archived and sent for storage to Pennsylvania. Records of hepatitis test results were destroyed because the law allows destruction of old records regardless of their importance to a patient or a doctor. When a new lab system was brought in, it did not port any of the previous lab history - there were issues with integrating two different proprietary systems that stored information differently. The Cardiologist and the Neurologists have their pieces of my patient's records in their offices which my patient's family is trying to obtain. One of the children is standing for hours trying to get MRI films from another facility - this is his third trip: first, he forgot to get the 'facility specific' consent signed while they figured out which of the same name records was his mothers; the next time around he did not carry enough money on him to pay and sign out the films and they were still sorting out the duplicate visit records that had not been merged!
My patient is a 72 year old mother of four and grandmother of fifteen who suffered a stroke from an irregular heart beat. She can't speak or swallow food leave alone walk on her paralyzed limb. I have already had to get the MRI repeated because the Insurer wants to know why I cannot send this woman home. The hospital informed me the Insurer was refusing to authorize payments for her days in hospital - I spoke to their medical director yesterday and he approved 'one more day' for a woman that clearly needs five more days; something that the Medical Director at the other end understands but is not authorized to approve by his employer.
My team is chasing their tails to wrap things up and have all the information so that the specialists can make the right decisions for my patient. Any copies of tests results that I had in my office were a result of my staff and my patient's efforts in trying to consolidate information over the years. Any tests that the Urologist sent out went to a different lab that would not send me a copy of the results even if they were asked to. The pharmacy never tells me what new medicines got started by any of those consultants or which refills my patient forgot to pick up. I have relied on my patient to remember Greek and Latin derived names of diagnoses and drugs that graduate students cannot pronounce. As a primary care physician I coordinate care - I spend 80% of my time trying to collate information, call pharmacies, check and reconcile bottles, discard duplicate medications whose doses were changed months ago - the list of chores doesn't end. My patients hug me and bring me Christmas cards and home baked cakes because they value my input- I keep them safe. That is not why I went to medical school. I can do much more for them if I could only get past this asinine system that encourages fragmentation of information and gives birth to medical errors.
Obama wants this to end. I cannot agree more. Electronic health records is the central theme of Obama's health prescription. Every hospital will be paid to ‘upgrade’ their technology. This will keep patient's safe, assist in data collection, improve efficiency and eventually help control healthcare costs.
Obama’s Score on having the ‘Right Vision’: 10/10
2. Right Knowledge:
Making everything digital is fine. I just hope it's all under one umbrella. A typical hospital has 40 to 50 software and systems in use - all different and unique. Physicians run between screens because patient labs are on one and X-Rays and MRI’s are on another terminal. At a machine level, these software programs don’t talk a universal language and work off their ‘own’ machines – servers that cannot be shared; programs that cannot be easily integrated. Any patient information has to be entered manually in each system - changes made to my patient's health data in one system does not automatically reflect in all other systems.
It’s almost like having to buy a separate device for every Nintendo game or software program and then networking the ‘server farms’ so that they can follow basic commands. You would soon need to accelerate your infant’s technology education so that you could eventually have ‘more hands’ attacking problems that the latest upgrade of software would bring to your abode! In healthcare, there is an update every day – whether it is drug or disease information or billing and payment codes. IT staff in hospitals do this 24/7 and within their department, there lie hundreds of such machines - each with ‘unused space’ – so much space that in a 2007 survey, there was $140 billion in excess capacity on the market and 77% of companies rated this inefficiency as being a ‘priority’ problem.
After hospitals buy more machines, IT would have to bridge every one of them to a national electronic data highway so that you and I can get a medical record when we need it. The costs are huge and all prior efforts at creating exchanges have failed. Obama’s plan of throwing money at the problem is reflexive. And primitive. He just has to look around and see how the development of Internet based products has solved this challenge for us in our homes. All we need today is an internet connection. We can log into Google documents and create, use, share and store all our files there. No hard drive capacity issue. No access issue since one could be at a party and access the document from a cell phone and work on it. Every time there is an upgrade, it’s done centrally and all users start benefiting right away – no one has to install, configure and reboot computers and devices anymore.
Now let’s look at what Obama wants to do. He wants to give away a staggering amount of tax-payer dollars so that hospitals can buy machines to become IT companies. Do hospitals and physician practices really need to run server farms and hire IT geeks to run them? Or should they be focusing on their core business, doing what they do best – taking care of people? It’s not like they have mastered that either - look at how NY area hospitals performed very poorly in the first ever patient experience survey conducted by the government and these hospitals are being penalized for poor scores on quality and satisfaction. (Go to http://www.hospitalcompare.hhs.gov and see how your neighborhood hospital scored).
The assumptions of yesterday cannot be the basis for our future work. The rest of the universe is no longer using server based systems of the 1960’s. They are using Internet based services. Why do Americans need to cough up 200 billion dollars for more of the same junk? Sometimes you need to abandon the past - just like those who had their heads in the sand building Hummers and Excursions instead of fuel efficient cars.
Obama needs to leverage the learning from the parallels drawn between the PC revolution and the development of Internet based services. Had we been left at the mercy of companies that make ‘servers and mainframes’ we would have server farms in our homes– storing everything from bank and credit card statements, documents, games to photographs and videos – literally running an IT department within our homes. But we are not doing that today. We use the internet to get us the service we need, when we need it, where we need it. Online gaming, video-on-demand and music-on-demand have made client-server obsolete. Why store locally, when you can store and access information globally? Even my data is backed up online. It’s cheap, efficient, reliable and painless. Best of all, I and my wife don’t have to be IT geeks to do it.
Hospitals don't need more machines and more IT staff to manage them. Hospitals need direction. They need better payments and easy access to capital to hire more nurses for patient care; upgrade patient rooms and lounges so that the patient experience improves. And all those ‘traditional’ Health IT companies that have been approaching this problem with the ‘server farms’ band-aid mindset – and are lining up ahead of Detroit’s CEO’s or in front of Senator Tom Daschle’s office with cookie jars and smiles on their faces – they all need to be shown the door!
Change cannot be more of the same. Obama’s team needs to shrug off lobbyist dollars and put purpose before self. Obama should know better than to allocate our nations scarce resources to the same recycled idea in the hope of getting a different result this time!
Obama’s Score on having the ‘Right Knowledge’: 0/10
3. Right Conduct:
This principle is about always trying to do the right thing to the best of one's ability.
Healthcare today is in the dark ages. We have a broken system where a provider has to provide service first in the hope of a possible payment 90 days from the date of service, at possibly 60% of the bill. Insurers dictate payments and routinely tell providers and hospitals to take it or leave it. Could I go to a Chevy dealer; even today; and dictate what price I will pay for their service or product? Can I retroactively pro-rate the fees for 'quality' of the service provided by my Attorney or Architect? Insurance companies constantly innovate to deny payments. Unlike physicians, their loyalty is never with their 'enrollee'. Their mission is to create shareholder value – denied payments do just that.
Another case in point is the mail-order medicine 'refill chase'. 10 days before your medicine runs out, you must call an automated voicemail system for refills. If you forget, you will need to pick up medications at a local pharmacy by paying cash. They don’t think you have vacation rights. They wouldn't let my mother pick her cancer pills a month in advance while she was going to India on an extended vacation. We had to find passengers to carry her medicines to India! They aren’t liable if your disease advances. By denying you a seven days of medicines every month via ‘process delays’ they increase stockholder value by 30% annually. We have thus created a society where we reward the denial of care more than its provision. In my practice, we print fax confirmations but can’t be sure that they have paper in their fax machines! Insured consumers face hurdles in getting their pills; the uninsured don't have these problems!
One way to look at it is that we have insurance plans that will pay for the service. Yet, we, the customers, need to constantly make calls, re-arrange our schedules just so that we can be plugged into our Physician's schedules when we are sick. Most specialists don't have openings for weeks. If you miss a Mammogram appointment you will fall back by 6 months. We do have the most advanced medical care in the world - we just can't get to it in time before the rash or cold disappears! And enough talk about Europe and Canada’s health systems. Their wait times for a Cardiologist is several months while their citizens pay some of the highest taxes on the planet. I don’t want to wait at a government run clinic with a ‘number’ and wait to be called like we do at the DMV. Their health systems represent yesterday. We need to look towards tomorrow. We’re Americans; we demand better.
We cannot secure the future of our citizen’s healthcare by merely tweaking what we have when we know it has not worked so far. Let's focus on results and value. Money ought to follow knowledge. Instead of paying hospitals for competing with each other and offer duplicated business products and services, it is time to have them compete for customers looking for quality and a better experience. Malpractice insurance regulations need to be re-worked so that our children won’t have to fly to India to have their babies delivered by Obstetricians. Instead of having businesses own and control a patient's information, consumers need to be empowered. We need to create a system that revolves around the patient - not the other way around. Cellular telephony and Internet were with the U.S. military for decades. Once ordinary consumers got their hands on it, they got into the driver’s seat and started a revolution that continues to transform our lives to this day.
A line from the gem of Puranas, the Vishnu Purana; would have helped us in 2008: “Leaders of Kalyug will be addicted to corruption…..wealth will confer rank and power; misinformation - the only path to success. Corruption will become a way of life…..ultimately ordinary people will seek the mountains - the last refuge in chagrin.”
America needs a leader that conducts with courage. Someone who realizes that healthcare institutions are up for bailout; next. One who sees tomorrow as opportunity that should not to be squandered. One that does not lose insight learned in 2008 as we embrace 2009.
Obama’s Score on having the ‘Right Conduct’: Remains to be determined.
Reference: The South Asian Times Article, Vol.1 No.37 January 3-9, 2009
