Today Tara Parker-Pope had a thought provoking column about the strains in the doctor/patient relationship -- and there are some good additional anecdotes and discussion on her blog, Well.

I have maintained for a couple of years that doctors are missing an opportunity to leverage their "trusted brand" (a.k.a the trusted relationship) by embracing basic Internet technologies to communicate more effectively, consistently with their patients.    The simplest example is think of all the information a doctor's office has and needs to distribute to patients -- info about their disease (pamphlet anyone), info about the drugs they prescribe, info about what to do before the procedure,  info about post-visit instructions and so on.    The doctor could "push" this information to the right patients easily -- using a basic CRM type system.   It may not be "personalized" -- but it would be relevant, timely, delivered in a form that patients could use/reuse the information and perhaps learn more, if they chose to in a self-directed way. 

I first learned about "information therapy" and the key role it played in improving outcomes from the founders of Healthwise -- and they are still pursuing this mission, with an expanded set of services.   When you think about -- you want information from the doctor -- and we know from our consumer market research -- the consumers want "trusted information" -- but they also want a lot more than the 2 minutes, shorthand version today's economic model supports in the typical office visit or phone call.

The opportunity is physicians could differentiate their services, extend their reach beyond the office visit and improve the value of their services (and customer satisfaction measures) -- if they could figure out how to deliver "information therapy" or other content they believe in -- to their patients.     If physician offices were like other small/medium sized businesses -- they would have figured out how to do this -- like many successful businesses in other industries have done.

I am sure lots of docs have done some really great things - but why isn't it more widespread?    My hypothesis is -- the economic motivation is not there.   Because of the fee for service, bureaucratic nature of physician reimbursement -- the innovative doc can't capture the incremental value being delivered.    See my previous post on the need for supply side flexibility to stimulate innovation -- this (information therapy, relationship management, brand extension) is precisely the type of service obviously being demanded by consumers -- but is not being 'supplied' by physicians - because they don't have the tools/flexibility to capture the value (or even experiment to find out).

Today the MSM had a good article from one of the premier journalists covering health, Milt Freudenheim about a CMS pilot project around the "medical home" -- which is simply a vehicle to motivate primary care doctors to provide 'better' care to patients with chronic or complex diseases.    The basic premise is that physicians can provide care that is both more effective (better outcomes) and costs less over the long run (prevents unnecessary acute problems) by 'monitoring' consumers during their every day life and not just when they visit the doctor with a problem.    Microsoft has actually designed HealthVault to enable this kind of 'connected care' using the Internet to enable communications and by enabling personal health devices to make it brain dead easy to get objective information from consumers on a regular basis.

The real question in my mind -- is why there has been so little innovation around how doctors figure out how to 'package' a bundle of services for consumers and charge them for it?

My wife likes to remind me of lots of examples where 'bundles of services' are both performed better than in traditional health delivery and consumers willingly pay for them.   The most obvious example is with veterinarians.   We have three dogs (just exiting the puppy stage -- all at 2 years old -- it is a long story).   We have a vet that makes house calls, has an electronic medical record for each of them, calls to make sure the Bella is taking her pills and that Mac's ear infection is clearing up -- makes sure that the routine vaccinations are done on time and so on.   She always calls to follow up on any given problem.    It is easy to connect with her by email or phone - -very unlike most folks experience with primary care.   Why is that?    It is not that we value pet health more than human health?    My hypothesis is that the vet business is largely a cash business -- and as a result it invests in technology and services (bundles) to attract customers in ways that a fixed price, reimbursement driven business does not.

John Goodman at NCPA has written extensively on this topic, you can learn more here.   The main point is there is not enough innovation on the supply side -- and one sees a lot more innovation (better outcomes at declining vs. rising prices in health) in the cash based businesses like cosmetic surgery and LASIK.   In general I think he is right -- and it has deep implications for future policy.

I also give credit to Chuck Kilo at Greenfield Health - who first convinced me (after beating me up in an argument) that true reform in health care had to start with how physicians were paid -- perhaps an obvious insight but one that is often missing in the debate of how to get to a better 'system' than where we are today.

The Freudenheim article points to the problem of a declining population of primary care docs -- and one of the reasons is the 'system' puts them in a box where they don't make enough money, they can't do a good job and to make more money actually means doing a worse job, not better.   How is that motivating or attractive?      I gave a speech a year ago -- to the American Society of Clinical Endocrinologists -- and foreshadowed the benefits of connected care through HealthVault (though it wasn't launched yet).   Many, many docs came up to me afterwards and said yes, they were using Excel or forms or other systems to get data from patients remotely - -but they were making less money while delivering better care -- how does this scale?    

There are other innovations going on outside of retail clinics and cosmetic surgery...but they don't get a lot of attention - perhaps they should.   I learned quite a bit about the economics of a physician practice from a real innovator on the delivery side (also in Seattle -- where concierge medicine got started); his name is Garrison Bliss and his latest venture is Qliance.    There is a whole society for folks trying to innovate on the supply side - -and they deserve support...because it may be innovations on the supply side -- some that will work and some that won't -- that will help us find the real answers to the dilemmas of improving health delivery and outcomes. 

I haven't blogged recently, because I took my family to Moscow and St. Petersburg to learn and experience more about this fascinating country with a rich and proud history – a trip that I highly recommend.

While I was there -- I decided to learn a bit about their health system and its challenges.   As is well known, Russia has substantial long-term challenges related to a projected decline in population and a relatively low mortality age.  The country is using its new wealth to address health infrastructure needs -- but as in most countries, the health system is big; it sits under different sets of jurisdictions (fragmented); and is largely operated at the local level.

I had the opportunity to visit a leading oncology hospital outside Moscow (#62).    It is set in a tranquil, park-like setting outside the suburbs and has multiple buildings on this relatively small campus.   Its new surgery center (less than 3 years old) is outfitted with modern equipment and a local vendor-driven, HIS-like system of which they are very proud.   Parts of the long-term bed facility were under construction.

The HIS system was built on Windows and uses Citrix terminal servers.   They demoed it and its broad feature set to me for over an hour, putting up with my incessant questions about how things worked.   They showed it to me in a small auditorium setting, which is used every morning by the head of surgery to go over the previous day’s results and today’s planned surgeries.  The system was pretty complete -- managing the obvious things like patient registration and patient data, up to and including identification of which patients should be prepped for discharged that day or the next day.  Reducing the length of a patient stay (the Russian average is much longer than in US) is one of the priorities of the administration, in order to reduce service wait times.

More interesting than the HIS system, was speaking with the deputy director of the hospital, who is still a practicing physician.   We had a very engaging discussion, which made it clear that he was quite proud of his facility, of the improved results he had been able to accomplish over the last few years, and the fact that an executive from Microsoft was interested in learning from him.  He opened a fresh bottle of a Russian brandy drink (it was late in the day) to share over our conversation.   He was proud that their HIS implementation had enabled him to operate the facility more effectively: manage drug costs better (major expense), manage his resourcing better, be able to tell which docs were doing well and which ones weren't (to intervene), and to improve overall capacity…the key basic things he needed to improve results.  

His main point was that he needed to get more done, (i.e. see more people, get wait lists down and so on), without any additional funding.   It was about managing priorities and resources to get the most out of them.  Now maybe that shouldn't be surprising -- but it was striking to me nearly 8000 miles away from home, in a dramatically different environment and economic/payment system -- that the needs were similar and that IT was being used effectively by pioneers to improve their results in meaningful ways.