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The Doctor Will (Not) See You Now

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The Supreme Court's much-anticipated ruling on the Affordable Care Act, monumental as it is for reshaping provisions around health care access, has focused the nation's attention on just one dimension of our health care crisis: the demand side of care delivery. But however access to health care comes to be defined, mandated, and funded, we are still left with fundamental questions and serious concerns around the supply side of the equation -- namely, what does the delivery of care look like? Is it of high quality? Is it affordable?

At the same time costs are spiraling and patients are absorbing their higher share, the experience of care has been diminished and degraded for patients and physicians. The intimate, and what physician-author Abraham Verghese calls "sacred," moment of care that takes place in the exam has been invaded by a Greek chorus of payer requirements and government mandates. One study of physician time spent with patients found that while face time has increased over the past two decades, both physicians and patients perceive it has declined. Why the disconnect?

One reason may be the changing nature of the encounter itself. In most exam rooms, the computer has become a central focus. The physician's gaze, once directed at the patient, is now drawn toward the electronic health record (EHR) that's come between them. EHRs designed without physicians in mind can turn them into transcriptionists and reduce patients to a collection of clinical measures and required fields. In a recent Physician Sentiment Index™ poll of 5,000 physicians conducted by my company and Sermo, 72 percent said their EHR distracts from face-to-face time with patients.

To make health care work as it should, a few fundamental things need to change around care delivery.

First, we need to design EHRs that serve the physician -- not the other way around (the majority -- 44 percent -- of physicians surveyed believe EHRs were not designed with the physician in mind.) The EHR should enhance and focus the encounter, removing unnecessary work and only asking for and providing the precise information needed to support and inform that point of care.

Second, we must apply the theory of comparative advantage to the work that's done in health care -- whether in the physician's office, ER, hospital, clinic or other care setting. We need to shift work away from the physician to other care providers, ensuring the right person is doing the right work at the right time with the right data. In the physician office alone, estimates of the proportion of primary care visits that can be handled by medical assistants or nurse practitioners, for example, range between 50 and 75 percent. Delegating work and empowering clinicians to practice to the top of their licenses not only reduces costs overall but frees physicians to be fully present with a patient when their complete attention and training is truly required.

Comparative advantage plays in both the mundane and in the highly strategic and potentially impactful. Routine work should be offloaded to others in the supply chain who can eliminate it, automate it, or execute it more efficiently at scale (we know through our own client data, for example, that providers must process more than 1,000 clinical documents every month.) At the other extreme, comparative advantage can be highly strategic, providing the means for patients and health system leaders to evaluate who does a procedure best at the lowest cost. How does the MRI team at hospital X stack up against the highly-specialized, free-standing independent MRI facility? The right technology and data sharing can enable this analysis in real-time, providing a much-needed window on cost and quality across the health care supply chain.

And what if we added a true marketplace for data exchange where providers were motivated to play nicely together for reasons that extend beyond the Hippocratic oath?

Ensuring the right people are doing the right work and that physicians are focused on the moment of care requires we facilitate the efficient exchange of health care information not only within practices but across disparate organizations. Whether it's through Accountable Care Organizations or other models, patient care will increasingly require the movement of patients and their data to the places and providers who can deliver the best care at the lowest cost. But care is currently fragmented and patients, by default, are burdened with carting their own health data from provider to provider, filling out redundant forms and replaying medical histories at every point of care. As a New England Journal of Medicine article recently reported, in close to half of referrals the receiving physician had no information on the patient sent to them.

To connect providers, we need health information to flow freely and securely, as well as an economic model and active market that encourages that exchange (like we have in almost every other industry). Health Information Exchanges (HIEs) have generally failed in this regard, lasting only as long as the subsidies and mandates that prop them up. Primary care providers still bear the brunt of information collection and distribution (in connection with referrals) to hospitals and other facilities without any financial compensation for the information provided. Until recently, it has been illegal for hospitals and facilities to pay referring physicians for the work required to supply necessary clinical and demographic information. As a result, this information is often unavailable, creating vast inefficiencies and breakdowns in care coordination. But a historic decision by the Office of the Inspector General of the Department of Health and Human Services in 2011 reversed that policy, opening the door to an open market where the flow of health information is not only encouraged but rewarded.

Addressing issues of who pays for health care is essential and merits the focus it has received from the Supreme Court. But should all Americans wake up tomorrow with complete access to health care, we would still be left asking: What exactly have we gained access to? As patients, we all want the same for ourselves and our families. If or when we face a serious illness, we want our physicians to be free of distraction and armed with the precise information they need, in that moment, to provide the very best care. We want them to have the time and the presence of mind to guide us through treatment and share their best science and their best selves when we need it most. To ensure that quality of care at a cost we can sustain, much needs to change that is not addressed by the Affordable Care Act, nor by its repeal.