#ehr, #hcr, EMR, HealthIT October 11, 2012

The Health Care Revolution Must be Clinician Centered

by Dr Nick

The New Yorker author, surgeon, Harvard University faculty member, and health policy adviser Atul Gawande told the President’s Council of Advisors on Science and Technology (PCAST) today that checklists could help improve the quality of health care and lower costs. PCAST members seemed enamored with the idea of standardizing treatment and procedures, and also discussed how to raise the academic status of those working in the field. But another PCAST member—Google CEO Eric Schmidt—saw what Gawande was peddling as a potentially lucrative new market for the search engine giant.

Here’s Schmidt’s dream of what a visit to the doctor will look like in 2015. It came during a question-and-answer session following Gawande’s 15-minute presentation, drawn from his new book, The Checklist Manifesto: How to Get Things Right. You can judge for yourself whether it’s sensible or scary.

“My question has to do with the model of health care that we’ll be facing in 5 or 10 years,” Schmidt began. “It’s pretty clear that we’ll have personalized health records, and we’ll have the equivalent of a UPC sticker with your medical history. So when you show up at the doctor with some set of symptoms, in my ideal world what would happen is that the doctor would type in the symptoms he or she also observes, and it would be matched against the data in this repository. Then this knowledge engine would use best practices, and all the knowledge in the world to give physicians some sort of standardized guidance. This is a generalized form of the checklists that you’re talking about.”

Then Schmidt made clear what was troubling him. “As computer scientists, this is a platform database problem, and we do these very, very well, as a general rule. And it befuddles me why medicine hasn’t organized itself around these platform opportunities.”

Gawande took a shot at responding to the billionaire’s bewilderment. “I think part of the bafflement occurs because the folks who know how to make such systems don’t understand how the clinical encounter actually operates.” But the bigger problem, he said, is that such a search would in all likelihood generate more heat than light for the harried physician, who typically has “15 minutes to manage six problems.” According to Gawande, “the three inches of guidance, explaining what the evidence suggests and so on, needs to be turned into a useful form that tells you what you can do.”

But Gawande is no Luddite. He told Schmidt that he’d welcome an app—”for your iPhone or whatever the new Google one is”—that could help him the next time he sees a patient diagnosed with a rare renal tumor.

Gawande found a receptive audience for his idea that the federal government create a National Institute of Health Systems Innovation to complement the work of the National Institutes of Health, although PCAST members suggested that he consider other administrative solutions. And they also shared his unhappiness with the relatively low status of health systems analysis. “My sense is that we don’t respect this stuff,” said PCAST co-chair Eric Lander. “We respect the cancer genome, but not checklists. What do we need to do to send a signal to the next generation of researchers that this is a high-class, worthy thing to do? What would it take to move the needle?”

“You’re absolutely right,” Gawande replied. “It’s not well respected. There’s a reason, after all, that I’m still an associate professor.”

Older piece from 2012 but an interesting point made by the ever insightful and eloquent @Atul_Gawande when challenged by a non-clincinas who was “Troubled” by the state of #HealthIT.
As Dr Gawande said

I think part of the bafflement occurs because the folks who know how to make such systems don’t understand how the clinical encounter actually operates

There you have it – it is easy to look in to healthcare technology and prescribe solutions based on your experience of finance, computers, C++ coding and any other discipline. But if you don’t understand the fundamentals of clinical care, the taking of a history and all the nuances involved in teasing out details from patients you can’t prescribe a solution that will work effectively

And in a notable humbling point Dr Gawande points out that even within the fences there is resistance to much of the application fo this technology

You’re absolutely right…It’s not well respected. There’s a reason, after all, that I’m still an associate professor

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Comments 2
  • It’s not impossible for an IT professional to sit down, listen and learn how the clinical encounter actually operates. It may not be the usual course … but not impossible. The past several years entrepreneurs have been focusing on ‘scenario based innovation’ … which includes use cases of end user needs, decision points and process workflow.

    BTW, if the consumer ever catches on to how the inadequacies in healthcare and HIT increase their costs and contribute to their endangerment the revolution will come from them.

  • Good point but the point still remains that understanding the clinical workflow is not easy to “listen and learn” – there is much that is not articulated in that process that clinicians learn through their training and experience while treating patients. This engagement has been limited and is improving but including clinical professional as members of the team not afterthoughts is essential.
    I agree patients will be a major driver in achieving a change in our current process and systems as they become partners in the care process vs customers

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