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Saturday, November 10, 2012

The flaws of encounter based healthcare delivery

I am reading Lawrence and Lincoln Weed's book "Medicine in Denial". I became interested in this book after seeing a video of Dr. Lawrence Weed's Grand Rounds presentation at Emory University which dates back to the early 1970's. I blogged on this presentation earlier this year (http://georgiacontrarian.blogspot.com/2012/07/failure-of-our-intuition.html). Dr. Weed popularized the problem based medical record concept. His views on information collection, analysis, and use were far ahead of his time and concepts that he recognized 50 years ago are only now getting more widespread acceptance.


The concepts are really rather simple. Dr. Weed believes that everything starts with information collection and that to move rapidly toward decision making and action before a broad information collection effort is undertaken leads to disjointed and sub-optimal care. Dr. Weed divides the tasks into choice, collection, and analysis. I similarly divide the tasks into collection, analysis, and decision making and group the choice of which data to collect into the collection step while adding the decision making step which falls as a consequence of the analysis.


Under the current conditions, we attempt to cram everything into a very time constrained office visit. We might do some modest preoperative work ahead of time but for the most part, we experience our daily schedule of patient encounters as a series of agenda-less meetings. We walk in cold and start the process almost entirely from scratch, hurrying to collect relevant data, taking every shortcut imaginable to fast forward to diagnosis and plan implementation. We structure the encounter to limit the amount of any patient push back, with success being measured by how quickly we can get patients to accept our snap judgements and shoot from the hip plans. So much for shared decision making except in your concept of this is that you share your decision and the patient quickly accepts them.


Dr. Weed recognized that many of the functions now undertaken by physicians under hurried circumstances can be delegated to non-physicians under less time constrained conditions aided by software which drives more comprehensive data collection. The net result COULD be that we enter the encounter much better prepared without the need to engage in extensive data collection. With data collection for the most part done and the data presented in formats enhanced to facilitate analysis and decision making, the physician's job would be to facilitate decision making and implementation.


The key to deployment of this model is to put in place the data collection piece. In my own operating unit within a large "integrated" health care organization (and integrated is in quotes for a reason), we have made strides in moving toward collection of structured data in the clinical environments. However, the tools we use are still focused on office based encounters. The electronic tools which we are using which allow for the collection of structured data allow us to do this ONLY when we have the patient in the office. If we have an remote interaction and we place notes in the chart relating to this interaction, it is stored not as structured data but only as text blobs which can be mined for data only with great difficulty.



I suspect that our circumstances are not unique. The electronic medical record a still structured best as a billing justification tool, not a communication and performance improvement tool. It will be a huge waste of money if we spend billions of dollars to deploy a tool which locks us into bad workflow. Key to moving to efficient and less expensive care is offloading tasks such as data collection from expensive providers and moving activities from high cost environments such as hospitals and medical offices to where the patient are. If the only place our electronic tools allow us to collect key information is in high cost environments and that the tasks can only be done by high cost providers, we are sunk.

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