Right Turns for Health Care?

Doug Elwood, M.D. — Thu, 10 Dec 2009 19:07:30 +0000

A few years ago, United Parcel Service (UPS) initiated a software program that assisted its drivers in maximizing fuel efficiency. Engineers at the company reasoned that formulating delivery grids in which drivers could continually make right turns would eliminate idling while waiting to turn left at traffic lights. These waits can be extreme, especially at large intersections, resulting in wasted gas. Additionally, it allowed right turns on red (except in NYC of course) so drivers could save time as well. This small alteration cut precious minutes off delivery routes, saving on gas money and delivery time. With over 88,000 trucks making 15 million deliveries a day, you can see how quickly savings might incrementally improve.

Recent articles on the health care reform bill have pointed out that it may be focusing on the wrong factors. Rather than identifying methods to cut costs and make the system more efficient, drafters of the bill are attempting to provide access without considering the full picture. As the costs of our health care system continually escalate, the necessity of addressing this situation is magnified. Perhaps the health care industry could learn a lesson from the strategy UPS adopted: that is, eliminate the waste and redundancy in simple processes to streamline the system as a whole. In doing so, costs may be dramatically reduced. A few examples are provided below:

Continuity of care
a) Having worked in the system for over 10 years, I can speak firsthand about this problem and its repercussions. Patients are routinely shuttled among specialties, physicians, and even hospitals. Though there are many examples I could use from a physician’s standpoint, one from my own life may best demonstrate this point. A family member was hospitalized in recent years to undergo a coronary artery bypass graft (CABG), one of the most invasive procedures in medicine. He thankfully went through it well and was eventually transferred to a subacute rehabilitation facility for continued cardiac care. His first night there, he had a reaction to one of the medications. Rather than send him back to the hospital that had just completed the seven-hour surgery and subsequently cared for him for over a week, they took him to a different hospital, one that does not even perform that procedure. I was aghast to arrive at the emergency room and hear the physicians there asking him for his history, his medications, and other pertinent medical information. The two hospitals are less than five miles apart and yet there was no communication, no continuity, and consequently no chance that he could receive exemplary care. The amount of resources required to diagnose and then treat him effectively were multiplied by this disjointed service.
Technology
a) Of course, one way to avoid the scenario painted above is to have an electronic medical record system that is universally accepted. Unfortunately, this technology has been “on the way” for years and is only being implemented piecemeal now for individual hospital systems which do not interact. The Veterans Administration offers a prototype of a national communication network within health care that seamlessly connects. Without a similar approach for the rest of the country, resources will continue to be wasted on collecting data that could be easily retrievable.
b) At the same time, advancements in technology are pushing physicians to implement them at record pace. Magnetic Resonance Imaging (MRI) for example, is now being used routinely for nearly every patient that walks through the door with certain complaints. The art of physical diagnosis is fading and newer, high-tech equipment is being used. The result is higher bills with often equivalent (or even worse) results. The fault does not lie completely with physicians either, patients drive this problem just as much if not more. There is a culture within health care that more is somehow better. Leaving a doctor’s office without a scheduled MRI makes many patients feel uncomfortable.
Litigation
a) Again, having worked in a hospital, it is very clear that decisions are made on a daily basis not because they should be or because they are in the interests of the patient, but because they have to be. If a physician does not order a test, he or she could be liable – this thought is omnipresent in medical care. Even with stringent documentation explaining the reasoning, most instances in which a physician did not order a test that could have benefited a patient would not be excused.

And these are just three examples, the system is rife with processes and methodology that wastes resources. Whereas at UPS, literally every turn and second of the day is timed for perfection, health care wanders in a seemingly endless maze of inefficiency. Of course, as Atul Gawande pointed out in his seminal article a few months ago, costs can be community based and heavily influenced by factors that are not directly obvious. Still, these issues arguably point to larger deficiencies, trends, and a communication breakdown.

One potential solution to the problem of skyrocketing costs is personalized medicine. Drawing on multiple factors of an individual’s history and genetic composition, personalized medicine theoretically is designed to empower patients to take control of their health care in ways never before imagined. Skeptics of this approach though are numerous, pointing out the complexity of the system and the challenges to individuals designing their care. The debate around this topic is sure to intensify in coming years.

For now, as the reform bill moves closer to approval, the impending inaction on this area of the problem stands out and is worrisome. It will take a concerted effort by all stakeholders to make the next big shift. Hopefully, this bill will start the ball rolling and lead to greater change down the road. For now, we’ll just have to keep waiting for our left turn.

Widmeyer Communications » Atul Gawande

Right Turns for Health Care?