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Saturday, September 7, 2013

Medical "paper work" and transparency

I read a very intriguing piece I found cited on Arts and Letters Daily called "The write stuff: how paperwork validates power and obscures meaning". It was written by Peter Lopatin and published in The Weekly Standard. It is a review of a book (link) titled " The Demon of Writing: Powers and Failures of Paperwork
" (Demon). The basic tenant of the book is that paperwork (which now may not require paper)  is an essential tool of the modern state because it is required for transparency and accountability. Lopitan writes:
The French Revolution did not merely bring about the end of the monarchy; it purported, as well, to institute a form of government whose legitimacy was founded on its claim to be, at all times, the representative of every one of its citizens. Necessarily, such a government would have to be accountable for its every action and transparent in its functioning. This notion was embodied in Article 15 of the Declaration of the Rights of Man and Citizen of 1789, which asserted: “Society has the right to ask all public agents to give an accounting of their administration.”

In earlier and simpler times, trust could be generated via personal relationships. Our need to have ongoing exchanges with others rarely extended beyond a small group, often kin. However, as our activities began to require larger networks, involving individuals and groups where we could no longer rely on relationships build upon trust, new tools to create trust we're needed. Thus written agreements and written documentation which allowed all parties to see that agreements were honored became essential. With the loss of personal relationship there was a huge need to create transparency. This the explosion of "paperwork" to facilitate transparency. 

I immediately saw parallels to what has happened in medicine and the changing role of the medical record. Until recent decades, health care delivery was primarily  an exercise in trust. Services were delivered locally by a small group of well known (and trusted) professionals. They were trusted to place their patients interests above their own. Tools to facilitate transparency and accountability were not particularly essential or valued. 

Fast forward and the world is different. For the most part health care is a business delivered by anonymous and perhaps interchangeable people with tenuous personal relationships (if they exist at all). To replace the trust that was lost from the  loss of personal relationships, tools to enhance accountability need to be found somewhere. Thus the rise of medical paperwork. The nature of interactions changed dramatically, as did the cadre of people delivering them. Financial stakes became huge. The opportunities for gaming and placing ones personal agenda ahead of the patient's exploded. We had no real options for creating transparency and accountability other than paperwork.

There is an opportunity here for replacing paperwork with big data. Data on interventions and outcomes is all about accountability and transparency. The issue becomes how to do this in the current payment environment. We collect data but it is not the type which allows for measuring what we want to hold people accountable for. RVU's measure how much individual providers do without accounting for how much value it adds to patients. Until we develop meaningful metrics, we will be left with paperwork.

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