Means and Ends

On Tuesday the great suits of the Senate heard testimony related to H/HC IT practices, universal healthcare, and other great stuff.

Kudos to the voice of reason, aka Henry Aaron, at the Brookings Institution.

HITS, the Health IT Strategist e-newsletter, ran this priceless quote:

Henry Aaron, a senior fellow at the Brookings Institution, told members of the Senate Budget Committee that increased use of electronic health records, e-prescribing and other high-tech tools "is a means, not an end," and then chided Congress for not providing nearly enough funding for the effort.

"The end is replacement of the traditional view of physicians as solo, all-knowing managers of each patient's care with a new model of healthcare as a team activity involving many specialist providers who work together," he said.

Henry's philosophy applies to many more areas of healthcare than IT.

Let's take overuse/abuse of the ED by frequent flyers, for example. Not the most PC of terms, and if you're not familiar with it, go ask one of those all-knowing ED nurses or docs to share the definition as used in common practice.

People who use/abuse the ED to indulge in drug-seeking behavior are a segment of the hospital population I consider "customers" (because I can't use the terms I'd like to employ on a PG blog) by and large, rather than "patients" - that is unless they're ODing or detoxing as they come down off an overdose of meds or possibly having a severe and very interesting allergic reaction to narcotics. But I digress.

In advocating for designing service lines that call to customers, I'm by no means excusing or encouraging this type of behavior. Nor am I a cheerleader for hospitals' continued treatment of non-emergency conditions in the ED.

Nurse and physician bloggers far smarter than I have posited a great solution: staff your ED with a triage professional full time (RN, PA, MD) who will refer those patients who are not acutely emergent following triage to another facility.

Some brilliant Einstein-like minds have even called for a deductible payable in cash or via credit card UP FRONT - funny how if you charge someone that 100, 300, or 500 bucks before you'll register them after the triage exam they'd suddenly find their condition wasn't an emergency after all.

Of course, there would be true emergencies that are rushed through triage to immediate care - acute diabetic ketosis, alcohol poisoning with LOC, etc. These "lucky" patients get billed later for lifesaving services rendered.

This new "are you an emergency or not" system may sound great, and be cathartic to suggest, but is excrutiatingly trixsy for several reasons.

First - let's just admit it. We're all scared to death of being sued.

Second - we will make mistakes and miss some cases that don't present in the traditional way (heart attacks, CVAs, etc) and people will suffer.

Third - this requires the hospital in which we are practicing to have a subacute or "step down" ED unit, such as an onsite Urgent Care center, Fast Track, etc. This means mucho dinero to design, build, staff, and advertise, because this is a unit that will serve "customers."

Fourth - this requires the hospital in which we are practicing to embrace that catchy MBAschool teamwork lingo and have an executive team that supports our decision and promotes an "emergency care for emergency patients only" view from the inside out, at EVERY LEVEL of the culture. If we are going to be specialist providers who work together as a team, let's start acting like it.

This won't be easy to do (understatement of the month) in a culture that does tend to think of emergency healthcare (based on personal rather than medical determination) as a right rather than a privilege.

This won't be easy to do in a culture where hospital administration is a four letter word that (some, not all) medical professionals view as a bloated, bureaucratic yes-team. We may have rightfully earned that stereotype in too many H/HC organizations.

The full-time "weed out" triage pro and emergency treatment for emergency patients are means to an end, rather than the end itself.

Even if all of these trouble spots magically vaporize into thin air however, we still won't have successfully arrived at a sustainable "end."

The end is less crowded EDs.

The end is quicker service for life and limb threatening injuries and conditions.

The end is the return of emergency medical professionals who are burnt out and tired of selfish customers who slurp up resources patients should be receiving. They signed on to save lives people, not to babysit and bus cafeteria trays.

The end is a wider range of health-improving, wellness-maintaining, money saving options for care targeted towards desired sectors of medical "consumption" by customers with non-emergency conditions.

The end is a system that works, makes some money for some people, and self-selects to offer low or free care to those who are truly disadvantaged, like my new employer.

We don't seem to have much problem envisioning the ends - now where are the minds and leaders who will design and implement the means?

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