In our past several articles, we’ve talked about the inherent similarities and differences between problem-solving for engineers and for physicians. In a nutshell, we found that much of their essential technique is pretty much the same—with a few key differences:
If we leave out the technical specifics, what we’re left with is People. Patients with free will to choose their own pathways. Sometimes they follow directions, sometimes they don’t. Sometimes they’re forced to make substitutions based on what’s available to them. You can’t feed a computer code into a patient and expect him to follow each command down to the letter. You can’t run a simulation on a patient. He either gets treated or he doesn’t.
Doctors, just like everyone else, like to “fireproof” solutions as much as possible. By thinking of all of the ways something could go wrong and trying to implement ways to prevent this from happening, physicians hope that their prescribed treatment plan will go off without a hitch. Short of inventing a crystal ball, how can we help them? This type of innovation could be incredibly valuable.
As mentioned previously, The Lonely Surgeon had the opportunity to speak on several webinars run by the Michigan-based company in2being during their “From the Frontline” segment in 2020. The goal of these discussions was to speak openly about some major areas of medical technology that might benefit from a little innovation to help improve patient care delivery. We chatted specifically about four major categories:
- EMR & Documentation
- Payor Issues
- Communication
- Compliance
Ideally, you might want to check out the in2being archive to see our actual discussions, but we’ll do a little dive here as well.
EMR & Documentation
We all have seen the pain and glory of the Electronic Medical Record [EMR]. Physicians have a love/hate relationship with it. It can make looking up information so convenient, but it can also drive you to jump out of the closest window as you try to navigate its screens… and buttons… and clicking… so much clicking… In truth, the EMR has amazing potential to help collect, sort and analyze all kinds of data that could eventually be used to predict patient outcomes and to prevent bad outcomes from happening! Wouldn’t that be incredible? Many health systems are attempting to develop these sorts of prescriptive analytics as we speak, but varying degrees of success are the reality at this time. As the Engineer would remind us, “garbage in, garbage out”—If the quality of your input data is poor, your output data quality will be even less.
We also note that not every health system’s EMR can chat with a different health system’s EMR. The big companies in this field are working on some standardized ways of communication, but full transparency still seems to be a long way off. Patient privacy issues are at the heart of this, but another concern is that EMRs are not open-source at this time. This is very much a business. If you are a third-party app developer working in the digital health space, you have probably hit your head against the bulwark of EMR proprietary software more than once. Finding common ways to share data in the same way that our telecommunications system works through agreed-upon standards is critical if we’re going to have true portability of patient data.
Payor Issues
Both physicians and innovators have run afoul of payors along the way. It’s a time-honored tradition. Physicians want to be able to prescribe a treatment and not have to worry about it not being covered. Innovators want to design products that help physicians to do this, but if they can’t find a way to get their product paid for by the major insurance players, no health system will use their stuff. This process is separate from just FDA approval [as if “just” FDA approval was a walk in the park anyway…] Product designers spend small fortunes with advisors trying to find the best way to get their product included with the CMS [Centers for Medicare & Medicaid Services] CPT coding index. To complicate matters even more, just having an assigned CPT code does not mean that the insurance payor will reimburse well for them. In fact, each payor may reimburse differently for the same code!
And who keeps track of all this billing? Large healthcare systems often have their own departments dedicated to picking out codes and submitting them to the appropriate insurance company, but it doesn’t end there. An insurance company may reject that claim. The biller then must figure out why that claim was rejected and resubmit it correctly if there’s any hope of getting paid for their service. It may be months before any actual money is received by the biller from the insurance company for claims made. And don’t forget—each payor may reimburse you for a different amount, even if it was for the exact same service! This all depends on what kind of agreement your healthcare system has negotiated with each individual payor. These rates can even vary by geography—you may be paid more for that appendectomy in Atlanta than you would be in New York City. It just depends.
There are new transparency laws for pricing that have been passed, but it will take time for this to significantly shift this arcane system of medical reimbursement that we use. My non-medical colleagues shake their heads in disbelief when they learn how this system works—or doesn’t. I know. It really is a terrible system, especially if you are a proponent of capitalism and the open market. But this is how things are. And just imagine how this works for a small private practice doc! How does she juggle all of this nonsense? It’s time-consuming and expensive. Do we need innovative ways for them to keep up as we muddle through this mess? YES! Innovation in the payor field is not easy, but it is desperately needed.
Communication
Your patient has a time-sensitive question for you. Perhaps he can’t remember some instruction you gave him regarding his wound dressing at his last appointment. Now it’s after-hours, and your office is closed. How does he ask you? Does he have to wait for an appointment? Can he leave you a message? By phone? Email? Text? Carrier pigeon? What if he’s elderly and only has a flip phone? A flip phone that he usually leaves turned off in his glove box in case of emergencies? And when you finally get his message, how can you reply back to him? Does he have a quality reference that he could look up instead of asking you? Or will the ubiquitous “Google MD” degree win out again?
Holy cow… If that last paragraph hasn’t convinced you that we need some good innovative technology in medicine, I don’t know what will.
Here’s another one—You are a physical therapist. During a recent session, you see that a patient has a new ulcer on his leg from a recent injury. It’s weeping and smells a little funky. Do you send that patient to the emergency room? You could, of course, just tell the patient to make an appointment with his doctor, but wouldn’t it be great if you could let the doctor know directly? With the patient’s permission, of course. Heck, as a physician, I definitely want to know if I need to see my patient for a problem like that! I might even be able to squeeze him in that same day so we can take care of his ulcer before anything else happens. By communicating with the physician about a common patient concern, that patient gets better care. That patient may also avoid an ER visit and an expensive hospital stay. All good, right? But how can the physical therapist let the doctor know? Patient privacy laws still apply here, so a simple text may not be good enough. You can’t send a photo of the wound over the telephone. Health system EMRs often have their own internal secure communication that will allow docs to send messages to each other, but what if you’re an independent provider outside of that system?
Hmm… More room for innovation work here as well. This is becoming a pattern.
Compliance
Ah, yes… The slipperiest one of them all! Compliance. It’s whether your patient follows your directions or not. Your computer will follow the code you give it. If something goes wrong, there’s probably an issue with your code. Your computer—in theory—shouldn’t just randomly decide to ignore your commands, even if it may feel that way sometime. Human patients, on the other hand, can get a little creative sometimes. A physician may give very clear instructions on a piece of paper as to what she wants her patient to do when he goes home. What if, however, the instructions are in a language that is different than what the patient understands? Or what if the patient is visually-impaired and can’t read the instruction sheet? What if the instructions call for a specific medication or dressing, but the patient’s pharmacy was out when he went to pick it up? Can he use something else in the meantime? What if he only takes that pill once a day instead of twice a day? And for the love of all that’s holy, what if those cigarettes just called to your patient?? How is he expected to ignore that siren song? Because even though you explicitly told him not to smoke, sometimes you just NEED that ciggy!
Sigh…
Compliance is a murky thing. Communication quality, communication timing and patient interpretation of instruction may all play a role. Supply chain issues are common. Humans are a resourceful bunch—if we see a way to patch a problem, we’ll probably try it. Resources need to be available and affordable to patients if you expect them to use these things. New digital health companies are trying to improve pricing and availability through phone apps for medications, but what about dressing supplies? Or home safety devices? How can we empower patients to follow our directions more effectively?
Conclusion
Indeed. We need engineers to help our physicians solve these problems. We can’t do it alone. The technical expertise of our engineering friends is beyond what we have in our own toolbag. Talking early and talking often about these sorts of problems is the best way for use to overcome these obstacles. Our patients need it. Your Aunt Minnie needs it. If engineers and physicians have so much in common, we need to leverage this in a way that lets us work together more effectively. The time has come to flatten out the silos and bring ourselves together as an innovation community. It starts with that loop: IDENTIFY, THINK, CHOOSE, TEST, REVIEW and of course REPEAT. We all know this. It’s innately how our brains work as scientists. CHOOSE to work together, my engineering and physician colleagues. This is where the difference begins.
Until next time…
— TLS
Photo Credit: Free-Photos | Pixabay
THE LONELY SURGEON 