Are There Economies of Scale in Medicine?

by francine Hardaway on June 27, 2009

I’ve been listening avidly to all the different points of view about health care reform, and the only conclusion I’ve come to is that almost anything is better than what we have.

On Bloomberg the other day, I heard a call for a systemic approach to the practice of medicine from Dr. Eliot Fisher, Director of the Center for Health Policy at Dartmouth. He said there are always better outcomes where groups of doctors collaborate and practice together, as in the Mayo Clinic, the Cleveland Clinic, or even less renowned group practices such as in Grand Junction, Colo. The efficiencies come when a group of physicians are all responsible for a patient’s continuity of care, and when they share information such as that possible with electronic health records (EHRs).

Dartmouth has studies that show these kinds of group practices cut costs, and yet we have relatively few of them in the US. Most physicians still practice in groups of four or less, usually four of the same specialty. And fewer than 20% of these small practices have EHRs. In fact, in Arizona, where EHR adoption took off after Gov. Janet Napolitano mandated it, another article just said doctors who had bone to EHRs were abandoning them because they were costly to support and impossible to learn. Your basic family practice guy or pediatrician, practicing what the docs call “Hamster Medicine,” where he/she has to see 60 patients a day for five minutes each just to support his office, does not have the time or money to shut the office down to train people on an EHR.

So I dread what will happen when these small practices are forced to implement a complex EHR like GE Centricity, which is both the market leader and the product with the worst user interface. GE has already started a lobbying campaign on behalf of its product, part of which consists of interest-free loans to physicians to install it.

The learning curve for Centricity is steep, especially for the bi-lingual staff of many medical offices, where wages are low and turnover is rampant. I have a physician friend who wrote an EHR himself, and then left that product with his old practice (where they love it) to move to another state. There, he found a group that had chosen Centricity not just for the single group, but for the entire region — and nobody could use it! They had abandoned entire parts of it because no one knew how it worked.

That’s shameful. That won’t lower costs. Lower costs will only come from software that works like or Yahoo — interfaces that make it simple for users to pile in mountains of data without even realizing they’re doing it. And to keep the costs down and the learning curve short, the data should be kept in the cloud.

This is, of course, horrifying to the privacy advocates, who have never run a medical office. Well I have, and I can tell you that when the doctor’s fax machine is overflowing with test results, they spill out on to the office floor or sit there in a pile, and anyone walking by can see them, until some harried front office person collects them and (perhaps) misfiles them in the wrong patient folder.

How do I know this? Because not only have I run a medical office, but I helped a group practice install an EHR, and one of their “pain”points and biggest reasons for going electronic was the loss of patient records due to misfiling or non-filing.

What other business runs as inefficiently as a medical office? None. What other business is more dependent on paper? None.

What other business could become 1/16 of the American economy without being forced into business process automation? None.

But forcing EHRs down the throats of sole practitioners isn’t the answer to reigning in costs. Collaboration is. Collaboration is also the answer to many medical errors and misdiagnoses. I’m not saying that we should “crowdsource” the practice of medicine–although that’s happening through various online Health 2.0 sites that consumers rely on when they have insufficient access to care — but I am saying it might be time to streamline these small practices, put them in groups, and allow them to talk to each other over lunch about the same patient. That way I wouldn’t have to tell my internist what my cardiologist said, or wait for the cardiologist to fax over my results to him.

Any kind of information exchange would help. And whose ox does this gore, unless it’s the commercial real estate companies who have been building small medical offices?

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