The line between inpatient and outpatient is not simply about location, it’s about responsibility for making decisions. My own recent experience with an orthopedic surgery made me realize what a hard line this is, and how it might be softened in the future.
Historically, Decision = Location
We have clinical decision support systems because, of course, the kind of decision is synonymous with the place: the clinic. An industry group to which I belong, the Collaborative Health Consortium, used to be called the Clinical Groupware Consortium. We changed the name because we felt that the changes we wanted to implement, to more patient-centered care, were more about collaborative decisions anywhere, not just in the clinic.
When we talk about the “point of care” we refer to a time and place where a decision is made, where a treatment is applied, or where patient services are delivered. The point of care has come to mean a one-to-one interaction between patient and provider, where the “magic happens.”
Digitizing the health system has created a historical precedent: decisions and treatments can happen anywhere. The location where things happen can change rapidly in a digital, connected and mobile world, and it should. Who wants to be in a hospital or clinic?
Jonathan Bush, CEO of athenahealth, talks about the “sanctity of the moment” in medicine in a great piece about the important job that medicine does, and the critical nature of the physician-patient relationship.
I agree with Bush, there is something magical about the moment you have with a doctor, but that’s increasingly because these moments are so rare. Trying to get a physician’s time can be like chasing the Holy Grail. Just try to get one on the phone. It shouldn’t have to be so difficult to get a decision, and it shouldn’t often require a one-to-one interaction. Could it be that the “point of care” is artifact of fee for service medicine?
Expensive ER visit, or at-home diagnostics?
What’s needed for decisions? Information, prior knowledge, a goal, and systemically learning what works best within a given context. Patients can now collect the relevant information, physicians should have the knowledge to apply, and the goal should be shared between the physician and the patient.
My example: Last week I received successful orthopedic surgery because, after careful research, I chose the right surgeon and the right facility; everything has gone much better than I could have expected. Still, when I left the hospital, it’s amazing how much things changed from the system’s decision to my decision.
Everything transitions from being the hospital’s decision to becoming the patient’s decision. Of course that has historically been a necessity. The biggest problem is data and communication. For all intents and purposes, this transition ends both the collection of data by the provider and communication between patient and provider. Patients can quickly lose the ability to make an effective decision without their own data and communication with a provider.
For now, you have your paper discharge instructions, but then it’s up to you to “monitor”. If things cross some line spelled out in your discharge instructions, you could call a nurse or your surgeon’s on-call doc or PA, but it will take 30 minutes for them to get back to you. If you’ve crossed a line, say, for an infection, they’ll want you need a urine test and a chest x-ray. The concern is that you may have a bladder infection or pneumonia that could spread to the operative area. They will call your surgeon (and presumably he or she can charge for the consult) and decide what to do, they’ll reconnect the data collection and communication, something you can’t do at home. Making the trip to the ER or primary care doc is about re-establishing these connections, the location becomes the communications network again.
So, the main decision when a) you’ve been discharged and b) are in a grey area becomes: should you go to an ER (or other facility) to re-establish these connections? The person on the other end of the phone has the same info that you have, so the default is going to be on the side of safety and send you somewhere there is a physician and diagnostic equipment. You must be in the same general location of a physician for a health decision to be made, but most of the diagnostic equipment could soon be available on the phone.
The greatest concerns in my post-op condition were thrombosis (blood clots), infections, and bleeding. Yet, all my body conditions that were being regularly monitored to detect these events in the hospital (oxygen saturation, heart rate, blood pressure, temperature) ended. I was left to monitor my temperature and looking for symptoms, which doesn’t seem like a big deal until you enter a grey area, as I did, and then I called and I waited (20, 30, 60 min. or more) for communication.
Should location change the data capture and communications?
As Eric Topol recently stated, “one day very soon going to the doctors is going to feel like going to the video store or record store: a distant memory.”
So, really, what’s needed is the diagnostic data. How soon before there will be rapid at-home tests for both bladder infections and pneumonia or other conditions that could lead to a bacterial infection?
In the past, as in the future, the information lies with the patient. We go to the doctor to access it, but that time is changing.
Patients are already starting to make their own health care decisions based on information they have can access. Angeline Jolie is the prime example. She had genetic tests done and she opted to have a double mastectomy to prevent or reduce her chances of cancer.
I shouldn’t need to call my surgeon. I could have an oxygen sensor and a temperature sensor hooked up to my cell phone, fed to my surgeon’s dashboard, ala AirStrip for OB/GYN patient vital signs. They should make the call in conjunction with a doctor without running up against the phone-tree firewall that exists between most patients and their physicians, and physicians should be paid for those services, either directly or on an outcomes basis.
Where Decisions Are Made
A recent post by an author from the Society for Participatory Medicine states that most decisions, even at the hospital, are not made at the bedside or in coordination with primary care. If the docs and the patient were all contributing the relevant data and decision criteria to the same platform or framework, this would all be much clearer to everyone. Decisions would be made when and where they need to be, not because of some historical precedent or after conditions have reached a critical status.
If we are to build a truly patient-centered system, it must extend beyond when patients leave the hospital or the clinic. Leading institutions might see themselves as a hub for patient-centered decisions (not matter where they are made), rather than a hub of physical activity, diagnosis and treatment.
As Eric Topol hammered home recently, much of the diagnostics and data capture will soon be done over cell phone, and institutions should begin planning for this new normal. All of this, of course, still hinges on value-based payment, which disconnects payment from location and time and reconnects payment to effective decisions. Meanwhile, we can’t simply push decisions on patients without giving them the necessary tools to make effective decisions.
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