Efficiency, the doctor will see you now
Multitasking, technology taking a toll on our ability to work smarter
Time is Money: A continuing series
Dr. Kathleen Myers was worried about maintaining efficiency as soon as she heard that all the emergency department physicians at Legacy Salmon Creek Medical Center in Vancouver, Wash., were going to start using electronic medical records.
Her concerns were well-grounded. She soon found herself in exam rooms with her concentration split between the patient and the tablet on her lap. She was looking down while typing, missing critical clues that might help her diagnose her patients conditions. Her doctor/patient communication was suffering. And at night, shed go home and spend two to three hours retyping the notes shed taken during exams so that they could fit into the uniform electronic medical records format. Something seemed wrong, if not backward.
Specialization the division of labor is the hallmark of an advanced economy, according to economic textbooks. The baker bakes because that is what he does best. The mechanic works on cars, because that is what she does best. We all do what we do best so that the economic engine runs smoothly and efficiently.
Electronic medical records are supposed to transform medical care so that every doctor or nurse at every facility can have access to a patients health history. Technology is supposed to be making all of us more efficient workers. We can access tons of useful information in seconds. We can communicate with one another instantaneously. But that wasnt what Myers was experiencing.
Do you really want your doctor typing is the bottom line, Myers says.
So Myers found six unemployed college graduates and trained them in the basics of medical lingo and the requirements of electronic medical records. They began following her and other emergency physicians around, constantly typing into the tablets what the doctors would otherwise be typing. And if editing was required after hours, they did that as well.
Today, Myers Essia Health in Southwest Portland employs 600 medical scribes and trainers who are sent nationwide to help doctors and hospitals deal with electronic medical records. Patients, Myers says, tell her it makes a difference to have her complete attention. Her charts, she says, are infinitely more accurate. Emergency doctors without scribes, she says, spend 30 percent to 40 percent of their clinical time typing.
Efficiency? Do you want your highest-paid provider, who has gone to medical school to learn how to take care of patients, spending 30 to 40 percent of their time typing and right and left clicking? Myers asks.
Myers has a study showing that doctors who use scribes see on average 0.8 more patients per hour. At their billable rate, it makes business sense to free the doctors from typing. And some nurses spend as much as half their work time filing out charts, she adds. Many are not fast typists. A scribe for the nursing staff could free the nurses to potentially tend to twice as many patients.
Few physicians outside of emergency departments use scribes. Hiring a scribe takes a bit of farsightedness, Myers says, since they have to be paid upfront and the savings realized by seeing more patients comes at the back end. And there isnt a billing code yet that would allow hospitals to bill health insurance companies for scribe work, she adds.
Myers says scribes are needed greatly because the people who designed electronic medical records were engineers, not the doctors who use them.
Theyre just horrific to work on, she says.
As for that technology/efficiency idea, well, one of the things technology has done, according to people who study efficiency, is to make generalists not specialists of us all. Doctors have become typists. Ikea has made amateur carpenters of many of us by selling furniture at lower prices as long as we put it together.
All of us have turned into travel agents, spending hours online trying to book flights and hotels when just a few years ago we would call a travel agent a specialist who would quickly take care of our reservations.
Technology, says Javier Calvo-Amodio, can make us
all more efficient, at least those of us who havent lost our jobs to it. But only if we control it rather than let it control us. For instance, not letting it make us do what we havent been trained to do, like booking our own airline reservations.
Calvo-Amodio, an assistant professor at Oregon State University who studies systems and engineering management, says in many cases we have no choice.
Technology is making the world more connected, he says. You stay specialized, you are not going to be able to stay part of that interconnectedness. Thats the way the world is going.
Surgeries in bulk
The Cleveland Clinic seems to have figured out how to make specialization work for its patients. Consider that every Oregon Walmart employee who needs heart surgery doesnt have the operation at one of the states many hospitals. Walmart pays to have all its insured employees in the United States and their spouses or caregivers flown to Cleveland so they can get their surgery there. It apparently is worth it to Walmart, which is the countrys largest private employer and self insures its employees, to pay for plane fares and hotels so their workers from across the country can have their heart surgery at the Cleveland Clinic.
Walmart isnt a company known for its warm and fuzzy treatment of employees. Its a company based on value and bottom-line efficiency. And the Cleveland Clinic offered Walmart and other large retailers such as Lowes deals based on predictability and efficiency.
Walmart pays the clinic a flat per patient fee that includes everything provided by the hospital and doctors. No surprises. If a surgical patient needs $1 million of care because of complications or future surgeries, the Cleveland Clinic provides that at no more cost.
So the Cleveland Clinic is incentivized to provide its care as efficiently as possible. In fact, if there is an incentive, it might be to cut corners and save the hospital money by providing poor care. But doing that would tarnish the Cleveland Clinics reputation. The clinics strategy, according to officials there, is to do a large volume of heart surgeries, which will gain them specialized expertise and make them better at the surgeries than other hospitals.
According to Cleveland Clinic spokesman Michael McMillan, Walmart is saving money on the deal, but not because the clinic is offering a bargain basement price.
The concept is, this isnt just to get the lowest price, but to get the best outcome, McMillan says. The best-value part of that is the price of the service but also being able to manage complications effectively and get the person back to work quickly.
The Cleveland Clinic, McMillan says, can tell Walmart and others that there will likely be less work time lost because the clinics heart surgeons are becoming more specialized through experience than surgeons elsewhere. The clinic performs more than 4,000 heart surgeries a year, with more than half coming from out of state.
Standardized care model
Two years ago, Boston surgeon Atul Gawande wrote an article in The New Yorker magazine in which he asked why health care couldnt be more like the Cheesecake Factory. Gawande found that the Cheesecake Factory had turned itself into an incredibly efficient chain of restaurants by systematizing everything, down to the one best way it instructed its cooks to chop carrots.
The Cleveland Clinic is doing something similar. By having so many heart surgeries and all of its doctors on salaries, McMillan says, the business of heart surgery can be, to some extent, simplified into a few best ways to perform it. Doctors have some leeway in choosing how to perform each surgery, but the hospital has developed standardized approaches that limit their freedom to individualize techniques.
We have a model of care organized to be efficient, McMillan says.
Yet few hospitals have been able to institute standardized procedures in the manner that the Cleveland Clinic and five other Centers of Excellence hospitals have for procedures that include knee and hip replacements, according to Gawande. This, despite evidence that there are best ways to perform most of the procedures. A big reason is self-image, says Portland State University business professor Mellie Pullman. No doctors want to be think theyre simply craftsmen.
Doctors are part of the creative class, Pullman says. They think that theyre the experts.
The Cleveland Clinic has decided to eschew the fee for service model that a number of health economists say stands in the way of health care efficiency. The hospital has no incentive to order extra tests or perform unnecessary procedures. The doctors are all on salary and thus incentivized to perform surgeries the way the hospital wants them done.
Health maintenance organizations such as Kaiser Permanente have been saying for years that fee for service health care is inherently inefficient, and business experts such as Pullman and the University of Portland economist Mark Meckler are starting to agree.
As long as you have fee for service, doctors will always figure out a way to make a little more, Meckler says.
Meckler says not every physician will order more tests or procedures, but some will because incentives always have an effect.
Incentives pay off
Kaisers Permanentes health maintenance model, where enrollees pay fixed sums to cover their care, is simply more efficient, Meckler says. National consulting firms such as J.D. Power and Aon Hewitt consistently rank Kaisers health plans as the most cost-effective in the Pacific Northwest.
Again, its incentives. The organization as a whole gets rewarded for people not getting sick, Meckler says.
Kaiser enrollees are constantly bombarded with emails and calls about preventative care appointments they need to make. Kaiser spokesman Michael Foley serves up an example of a prevention model that hasnt spread widely to the world of fee for service. At age 50, most adults are urged to get colonoscopies to screen for colon cancer. Average national cost? About $1,500. One out of three adults dont get the screening, and among minorities, even those who are insured, the numbers are much worse.
Since Kaiser is paid a flat fee for all treatment expenses, Foley says, the hospital/insurer has more incentive than other providers to make sure its enrollees never get colon cancer, which is expensive to treat. So starting at age 50, all Kaiser enrollees are annually sent an envelope into which they are asked to mail back a small stool sample. That sample is then tested for markers that might indicate colon cancer.
The test, Kaiser physicians say, is nearly, but not quite, as sensitive as a colonoscopy. And when the rare test comes back positive, a colonoscopy is ordered. Each test costs Kaiser about $40.
This year, Portlands Kaiser Center for Health Research completed a study which involved providing the tests to 869 local patients, most Latino, about half uninsured. Nearly half sent the test back with their stool samples a major gain in overall screening, according to Foley.
Efficiency isnt all about specialization and incentives, Meckler says, but a lot of it is. Meckler says society overall is more efficient today than it was a few decades ago, but he qualifies that statement. You have to consider, he says, who is realizing the efficiency gains.
Remember Tom Sawyer? In Mark Twains book, young Tom was told he had to paint his Aunt Pollys fence. Rather than do it himself, he convinced friends that fence painting was fun, and they did the job for him. A lot of us have been suckered just like Toms friends, Meckler says.
Economists use the term externalizing costs. That means somebody else pays. When we spend hours online making our own vacation reservations, overall efficiency has increased because a middle man, the travel agent, has been eliminated. Airlines used to subsidize travel agents. Now theyre saving money. Thats efficiency for the airlines.
Theres real efficiencies and then theres fake efficiencies where its more efficient for us, but it dumps on somebody else who does a worse job at it, Meckler says.
Meckler says hes experienced his own personal Tom Sawyer effect at the university. Years ago, he says, he had an administrative assistant or secretary to type tests, return calls, even make his business trip reservations. That middle man has been eliminated, which leaves Meckler doing all that secretarial work when he could be teaching and researching.
That false efficiency the same one encountered by Kathleen Myers when she found herself in need of a medical scribe is the result of a short-sighted approach to efficiency, according to Meckler.
We overemphasize saving resources, he says. But efficiency is also using the same amount of resources to get more. Were worried more about saving resources than we are about improving
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