Healthcare Systems Process Reengineering, I: Vision

In two previous posts, I’ve discussed a vision of longitudinal healthcare responsible for people, rather than illness — and for the role that computers and medical informatics could play in making such systems possible. Those two posts discussed the ideas as they would apply to Latin America and to developing countries.

Actually, though, I originally thought about these ideas in the context of healthcare in the United States. I was working at the WHO coordinating center for medical informatics at Norwalk Hospital. By observing physicians daily, and attending rounds with them, I was trying to understand how they made decisions, how the hospital worked out its cost model, and how to follow up on care so that patients stayed well.

The International Society of Computers in Anesthesia and Intensive Care invited me to speak at the 17th ISCAIC Meeting, organized by Yale University, and held 16-19 April 1997. So I took that opportunity to give a series of talks. The first one dealt with the vision: what did we want to achieve? The third one dealt with software implementation and, though perhaps visionary at the time is now of course seriously obsolete in its details. However, I don’t think the vision is at all obsolete — even though it’s express in the now somewhat archaic terminology of “business process reengineering.” It seems more urgent to me now than it even did then, and one of my major projects now is developing an actual implementation of the software using today’s technology.

This post gives a brief introduction, but you can download a pdf copy of the complete set of overhead slides that I gave in my 1997 lecture: Healthcare Systems Process Reengineering, I: Vision.

The ideas of Healthcare Systems Process Reengineering

One feature of the continuing and unsuccessful efforts for healthcare reform in the US has been the failure of physicians to lead in articulating a new vision to deal with the perceived problems:

  • that healthcare costs too large a portion of the GNP and of the Federal budget;
  • that despite the high cost the general quality of care is not high compared to other developed nations;
  • and that too large a portion of the population cannot afford even adequate care.

The medical community has largely been reactive, so although change has been inexorable, it has been driven by insurers rather than by providers or consumers.

This paper contributes towards a new vision of healthcare systems in which physicians take leadership, in cooperation with other health providers and with employers, insurers, community organizations, and government agencies. The ideas in this paper are only a first draft: they need interdisciplinary work in order to make them practical.

In many cases it is more appropriate to speak of patients, rather than of diseases. A patient presents with a set of symptoms. He also presents with a history that colors our interpretation of the symptoms and limits our choice of therapy. We may diagnose more than one chief complaint. We may not be able to settle on a definitive diagnosis before we need to initiate therapy. Rather we have a differential diagnosis from which we progressively rule out possibilities, as disease, testing and treatment evolve; and perhaps it is only afterwards that we are able to rule out all the possibilities but one. In parallel with pursuing the differential, we may also be treating symptomatically and trying to maintain homeostasis in the light of physiologic law.

The key is longitudinal health. If a COPD patient is hospitalized, we are concerned with how well the hospital does its job, but later it is more important to ask how the system could have staged previous care to have avoided, or at least predicted, hospitalization — and, more, to have prevented smoking.

The object is the long term health of each individual. This is the basic process in terms of which the healthcare system can add value and that we want to re-engineer so that it is natural, easy and economical for providers to ensure end–to–end service.

Illness has a tremendous social cost:

  • It hurts quality of life of the individuals involved, i.e. eventually everybody.
  • There is a cost to the economy in days of work lost or in poor quality work.
  • It usually is more expensive to get people well than to prevent them from getting sick in the first place.

We tend to think that these costs are being paid by somebody else. They aren’t. Directly or indirectly, we pay them.

It is a corollary of this point of view that wellness is primary: the moment a consumer becomes ill, the system loses. A further corollary then is that individuals, communities and community agencies have to be enlisted as active partners rather than as passive recipients.

In real world terms, the traditional model of health care is poorly applicable:

  • The distinction between “what happens before you’re sick” and “what we can do after you’re sick” doesn’t correspond to any boundary useful to the consumer.
  • Within health care, although specialization is important in providing depth of knowledge and resources, where needed, and independence among providers is important in preserving individual responsibility, these have to operate within a model that views the world seamlessly through the consumer’s eyes.

The fundamental process that the healthcare business is about is the long term health of individuals in the community: keeping them disease free, rapidly and effectively resolving illness when it does occur, and slowing the progression of degenerative diseases. If we can provide, and document, this service — longitudinal health for individuals — we can prosper in an era where health care is increasingly purchased in quantity by employers with an interest in using their fringe benefit dollars to protect the productivity of employees and the well being of their families. This kind of end-to-end service cannot be provided by hospitals or physicians acting in isolation: it can only be provided by systems delivery of a variety of services centered on the customer’s needs. These providers need not be part of the same organization, but they must have the means and the incentive to cooperate.

This paper contributes towards a new vision — Healthcare Systems Process Reengineering (HSPR) — in which physicians take leadership, in cooperation with other health providers and with employers, insurers, community organizations, and government agencies.

This new model of healthcare requires coordinating the activities of all the disparate elements involved, and doing so poses a difficult systems problem.

The role of the HSPR software is to provide the fundamental enabling communications, information and knowledge engineering infrastructure that will enable the partners in this new model of health care to work and to work together.

Download a pdf copy of the complete set of the overhead slides that I gave in this lecture: Healthcare Systems Process Reengineering, I: Vision.

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