Affordable Care Act's Elephant in the Room -- Political Pun Not Intended

Health care is important to all of us and it is little wonder that the topic of reforming it has sparked such emotion. Amongst an audience of erudite thinkers, strategic planners and thoughtful leaders, I am, however, shocked that it has not roused as much factual and intellectual debate as would be necessary to handle such a crucial topic, particularly when the system is in crisis. The press, the public, my colleagues and the politicians have all resorted to the plucking of heartstrings claiming a lack of humanity with every opinion, when in fact what we have is simply an emperor with no clothes. Our esteemed health institutions have their greatest minds calling the obstruction of a poorly explained health care reform bill a threat to America itself. Have we really considered the clear facts and exposed the underlying misaligned incentives to rationally address the issue? Or are we just using this to vent our most personal political preferences?

The government, in cooperation with the press, has provided checklists, action items and cliff notes to help us navigate the new Affordable Care Act, but I am left bemused as the simple principle of making transparent and affordable payments to see my doctor is not what I actually get. We need an explanation for why we have an antiquated model supported by yesterday's information technology, empowered by a confused consumer, delivered by a beleaguered practitioner and paid for by the consumer in collaboration with our redistributed tax dollar. A system that seems to burden itself daily with further administration, support and maintenance is only going to make choice cost prohibitive. The elephant in the room: "Affordable health care with an old model of care delivery is a broken solution that will be costly to maintain, let alone implement."

We are being fed the glory of technology without realizing the paucity of utility and usability of these systems. The widespread belief that the Affordable Care Act will make care more accessible, ensure more affordable health care and enable better care, is a principle with no practical or tested basis. The act is tied to the implementation of superhighways and exchanges that enable data flow, interoperability and transparency. The reality is we have had very slow penetration - over a decade now -- of the very backbone infrastructure required to manage and maintain a complex service system, as is health care and interoperability is at a standstill. We have not been educated on the tools being utilized, nor have we had sufficient expert opinion that these are the right tools or that they even work. Simply empowering us with access to our health care data was a failed experiment in the hands of Google and Microsoft. I guess the government knows better.

When you begin to look into the busy practice of care, whether in a hospital ER, private clinic or busy surgical/medical center, we realize that barriers to access the expert are well entrenched and reimbursement manages the care pathway and site of care. It was an initiative led by the prior administration of passing computerized medical record legislation, with a view to spending hundreds of millions of dollars in going paperless, to make care efficient and improve access to the physician.

Since 2006, when this initiative began, we have seen very slow and complex adoption of modules of the solution and even superficial scrutiny will reveal the fixtures are not in any way complete. The HITECH act as a part of the ARRA of 2009 was then enacted to fit hand in glove with the affordable care act to promote and expand the adoption of health information technology to optimize population health management. This time we were clear who was paying for it: the taxpayer. We continued to ignore the many heated debates on the impact of the technology to productivity, costs and ultimately clinical outcome and seemed astounded to see that there was in fact very little clear benefit. Every experiment starts with a hypothesis and we trial the hypothesis, review the results and make assumptions on a better solution without any guarantee that the hypothesis was correct. It seems we skipped the analytical process we would normally have used in assessing optimal solutions to a crisis. The surprise is we assumed someone had clearly tested the infrastructure scenario and new the impact on outcome. The shock is this experiment cost hundreds of billions of dollars. Further insult to this costly injury is when you hear leaders of hospitals state that the advantage of the electronic conversion is that now we can read the doctor's handwriting!

Granted, there are peer-reviewed publications analyzing the impact and understanding the metrics with vigor and thoroughness, and this is not entirely a negligent exercise but is certainly an uncontrolled and unconstrained one, with the onus of accountability riding squarely on the practitioner's shoulders. Proper legislation would have taken into account the impact data, the utility and the functionality to test scenarios that support the political goals that are touted as the core of the reform policy. It is clear that no-one with any project management experience was involved in this civil engineering endeavor and that we are now frightfully short of utilization, integration, interoperability and engagement especially for the public, to make any lofty claims of being ready to make health care accessible and affordable.

Getting back to the busy practitioner, nurse or doctor in the clinic, they are now burdened with administrative duties of curating the information into the system, searching for information that does not exist and cross-referencing paper charts, responding to constant alerts for system tasks that did not exist in prior safe practice and see more patients in one day than before to be compliant under threat of not receiving incentive payments from the government. So hospitals now hire navigators or business shepherds to keep these high performers on task, but productivity is falling, doctors are considering early retirement and despite the convenience of quickly accessible information online, are suffering from IT fatigue that is not letting up. Some systems are almost a decade in deployment of the software and not even close to independently functional and many are switching vendors in the hope of a better system.

Had the computerization of medical records been the panacea to access and care management improving productivity, it would have taken foothold much prior to the current state. The innovation milieu is left stifled by the burgeoned health care system aftermath of trying to absorb this badly designed solution. This federal mandate had a built in punitive impact on payment for care on the back of the old model for reimbursement. This only complicated the ability to service the needs that have been dubbed meaningful use delaying their achievement. The conundrum is not why is this not working but how did we get to such a state of implementation disarray?

Why the optimism for participating in changing health care then? The customer, providers and patients are jumping ship, and therein lies the opportunity. There is a clear realization of process improvement and the empowerment to make their own choice. Inadvertently we have accelerated change by forcing a broken system to take on too much. To begin the future, a redesign of health care is needed, with virtual scenario testing, nimble design changes, and alignment of goals with outcome measures. Bringing innovators, politicians and consumers in a collaborative network and allowing for organic shift is the leapfrog we need rather than further stringent and confounded policy. Let's get back to servicing the unmet need -- accessible and affordable care.