What is Working in Healthcare?
Guest post by Edgar T. Wilson, writer, consultant and analyst.
In virtually every context that question might be asked, we struggle to give an honest, accurate answer.
It Works If You Believe It Works
Is the medication working? Difficult to say–it may be the placebo effect, it may be counteracted by other medications, or we may be monitoring the wrong indicators to recognize any effect. Is “working” the same as “having an effect,” or must it be the desired effect?
Alternative medicine confounds the balance of expectations and outcomes even further. Right at the intersection of evidenced-based medicine and naturopathy, for instance, we have hyperbaric oxygen therapy, or HBOT. These devices are as much in vogue among emergency departments (to treat embolisms, diabetic foot ulcers, and burns) as holistic dream salesmen (to prevent aging and cure autism, if you believe the hype). When the metric being tracked is as fluid as the visible effects of aging, answering whether the treatment is working is about as subjective as you can get.
As though the science of pharmaceuticals and clinical medicine weren’t confounding enough, you can hardly go anywhere in healthcare today without politics getting added to the mix. In the wake of Trump’s victory in the 2016 presidential election, you have observers and stakeholders asking of the Affordable Care Act (ACA): is it working?
There’s Something Happening Here
It is definitely doing something. It is measurably active in our tax policy, for instance: 2016 returns are heavily influenced by the incremental growth of the ACA’s financial provisions. Of course, the point of this tax policy (depending on who you ask) is to influence behavior. As to this point, there are some signs that, again, something is happening: among young people, ER visits in general are down, while emergency stays due to mental health illness are up. We changed how healthcare is insured, and that changed, in turn, how we access our care. But is it working?
Politics, like medication, seem heavily influenced by expectations, except in politics we aren’t particularly good at controlling for this placebo effect. If you expect a policy or an officeholder to fail, you will find plenty of evidence to vindicate yourself; if you expect them to succeed, it is no stretch to filter outcomes through conditional sieves to turn every outcome into a qualified success.
And that all brings us to our EHRs, information exchanges, all other extensions of the effort to digitize more and more of healthcare. We are billions of dollars, several years, and waves of adoption into our commitment to meaningful use, HIEs, and all manner of platforms for billing, coding, and documenting patient encounters. Critics and advocates agree there is no viable road backward from here. What they cannot seem to reconcile is how to assess the outcome of all this change and disruption to how healthcare operates. Is it all working?
A Million Ways to Win
To paraphrase former president Bill Clinton, it depends on what you definiton of “working” is. EHRs used to be an elective tool; now they are effectively mandatory. They used be vary widely in what they could do, and how; now, they still vary, but slightly less so than before MU.
Documentation used be achieved through a patchwork of paper, dictation, electronic charting, and notes; now it still is, but caregivers are increasingly accountable for their EHR documentation. All the while, exactly how these tools are being integrated, and to what extent they are being coordinated, remains as difficult to measure discretely as ever.
There is much work being done; is it all working? The answer seems to depend heavily on where along the continuum you are invested. At no point have all the stakeholders (patient included) agreed on a single measure of success. Worse yet, progress at every stage is incremental. While the whole impact may be revolutionary, the progress is staggered, which invites criticism. We simply are not patient with incremental progress.
Unfortunately, that is the ugly truth of our reality that, if anything is going to “work,” we have to come to accept. This was always going to be an incremental process. At every point that invites criticism, second-guessing, and Monday morning quarterbacking–and that is fine. But if we move the goalposts with every step, progress becomes impossible to measure–much less whether what we have and what we are building is “working” any better than before.
Getting Ready for Prime Time
When Saturday Night Live first premiered on NBC, the cast was known as the Not Ready for Prime Time players, a riff on the uncertain future of the program and its stars. Every subsequent season has been alternatively panned and praised, with critics asking without a hint of irony whether the current season is doomed to be the last.
The digitization of healthcare seems to be trapped in a similar state of perpetual revalidation. When meaningful use launched baseline EHRs across the country, clinicians and hospitals all decried the platforms as, essentially, not ready for prime time. The same goes for MACRA, and efforts to piggyback on digitization to shift reimbursement from quantity to quality.
SNL is still airing, driving conversation and sending its cast from the Not Ready for Prime Time stage to Hollywood’s A-list. Likewise, the incremental crawl of change throughout the healthcare system is still proving itself, but as it moves along, we can see that parts, at least, are working.