Accountable, Affordable and Accessible Care: To Go!

With the enthusiasm of the better connected and affordable care vision, we have oversimplified the delivery and perhaps tarnished the vision of more accessible care. It all appears at first blush to be a good idea, which is what the policy is, a mere first blush. When you dig deeper into the strains of care delivery, you begin to understand how impractical this notion of accessibility is with punitive compliance testing that impedes care communication. Underlying the policy is the actual infrastructure and implementation saga.

In an effort to understand the sentiment behind networks and accessibility, I reached out to healthcare leadership across the country. The response was resoundingly the same, and is well summed up by Charles Schleien, MD, Chairman, Department of Pediatrics LIJ NSHS.

"The major constraint in dealing with large care networks is the number of individuals required to be involved. There really aren't enough key personnel to deal with this level of decentralization. We need a more interoperable communication link to manage patient flow."

The Affordable Care Act and its accompanying tech and compliance features are forcing small and large providers to decentralize care as a part of business efficiency whilst consolidating the referral network as a measure of revenue security. This is changing everything, and revealing gaps and inadequacies of the plan as there is no underlying infrastructure. Many hospital leaders are frustrated with the inequality of the dwindling payment environment and the sudden cost shift to the consumer, which literally passes the buck up the chain so that those seeking exchange based care are not those originally targeted. The impact is to rope in the necessary referrals to control revenue sources, creating the environment of hired and capitated physicians, which we are all aware is not going to reduce costs and is largely untenable given their autonomous nature. Classic efficiencies of scale do not apply when the parent entity is not equipped to handle simple things like call services. Joint ventures to outsource services are growing, but without the quality purview of clinical leadership as seen in institutional environments.

So now you have the issue of actually coordinating all this care and keeping an efficient system. This tandem strain has come without a capable tech infrastructure to enable it. Ah, but we have digital healthcare records you may say. But, they have such operational inefficiency and have not delivered on billing or productivity. Then there is the looming billing and coding system change, ICD-10. It's a wrecking ball coming at a wall made fragile by complex EMR deployments. Physicians have come under great scrutiny for competency when in fact they do a better job if not told to conform to drop downs and misguided short cuts that eventually lead to visits by regulators calling out cut and paste fraud. The greatest fraud occurring is the façade of accountability forcing physicians to be administrators and not patient care managers.

How do we get out of this tar pit? Healthcare needs physicians back on the vines. Their conversation, network links, and rapid assessment of disparate data sets are what makes them diagnosticians and clinicians. They need a tool that talks their talk and integrates into the medical record enabling more time for clinical decision-making. They need a new class of record and that is the digital or electronic care record (ECR). By enabling their communication and conversation with patients and colleagues we can focus on functional multi-disciplinary teams that can deliver better care. The focus of technology in care should be, as Dr. Schleien stated, on "interoperable communication link(s) to manage patient flow." We have to get back to caring by being more accessible to the patient and our colleagues. Not the system