A recent editorial in the New England Journal of Medicine asks who is “Daring to Practice Low-Cost Medicine in a High-Tech Era” raises some very interesting questions on whether we are necessarily doing the best thing for outpatients when we take advantage of “the vast array of new tests, new pharmacologic agents, and new diagnostic and therapeutic procedures” currently available. The author notes that “most doctors are intensely risk-averse” which is true because we are looking after people’s lives. He goes on to say “we don’t tolerate uncertainty” which I guess links to our scientific training and usually inherent mind set.
This started me thinking, is health technology playing a role in driving this behaviour? Does the ability to order with the click of a mouse makes us more likely to order a test than having to write it down on a piece of paper. My experience is that with decent clinical support tools, the computer actually gives you an opportunity to think about what you are ordering, and if done properly may even stimulate thought patterns around test and drug ordering we had turned off a long time ago. We can influence doctors ordering, but they will still remain risk averse.
The other thing I started to think about is why are we so risk averse when we manage patients in the community. It could be because we are largely isolated from their daily activities, so when we do have them in our rooms, or in the hospital we try and do everything we can for them. Let’s manage all their physical conditions, and while we are at it let’s add some medications for their depressed mental state, because they seem to be sad after waiting in our crowded waiting room to see us and be told about everything that is wrong with them.
What if we had a better idea of how they were in their own home environment. Rather than bombard them with a lot of questions about their body, their mind, and their social life in in one sitting, what if we could ask them relevant questions at relevant times. How did you sleep, first thing in the morning not at 3 in the afternoon, or while they are lying in a hospital bed waiting for a test result.
It seems to me that tools that enable us to communicate more regularly, if even in small bursts, and not necessarily in real time may give us a better understanding of the patient we are dealing with. Then we can practice high quality and still low cost medicine, because we can afford to be a little less risk averse. After all we know in pretty short time how whatever we are doing is affecting the patient, and we can respond appropriately. We can find out what their blood pressure is at home on a normal day, not after catching two buses in peak hour to get to our rooms.
Can we do this and still deliver high quality care? As long as the model of care allows us to interact with the patient as required, without penalizing us for doing so, then I believe we can. What does that mean, well today we get paid for spending 15 minutes with the patient and trying to solve as many problems as we can in that visit. What if we got paid for managing them differently, a base amount for planning and a fee for service for each interaction, more for long interactions, less for short. Why do those interactions need to be in person, when we can do a lot of it remotely, via video if we need to see the patient, or just by asking them the right questions via some other means. Flexibility is the key to gathering good information, use the right tool for the right information and you get better information.
Then there is the whole question of patient self management. How do we share some of the burden of care and associated risk with the patient in a way that makes them feel like they are getting high quality safe care, but also efficient care. It is hard in a country like Australia with the government covering much of the cost of care, but today we are finding more and more of the cost being diverted back to the patient. Just this morning there was the announcement that new drugs being added to the PBS will be limited, so patients will have to decide whether they are willing to pay for some of the new drugs themselves.
To help us reach the goal of high quality low cost healthcare wee need to enable the clinicians to manage the risks associated with the care more effectively. That means giving them tools for managing and monitoring their patients, and importantly reimburse them for doing it. We also need to facilitate the communication between the patient and the clinician, where it makes sense, from the patient’s home, not from the clinic or the hospital. Keep those facilities for the people that need them,, and manage the bulk of the healthcare needs where it is located, back out in the patients community. Finally we need to educate the patient about their condition, their treatment, and how to play a more active role in managing their health. Not just campaigns telling them to lose weight and stop smoking, but targeted relevant education provided in a way they can use it.
Home telehealth solutions, especially those that take advantage of the improved communication infrastructure provided by broadband can do that today. Yes they cost something to put them in place, but if they enable us to move to a model of high quality low cost care, then they very quickly pay for themselves. Until such time as they are properly utilized we will continue to pay for inconvenient and unnecessary consultations, risk averse behavior and high cost and high inconvenience medicine.