Is the Iron Triangle of Health Care a Law or an Observation?

A recent commentary in the Journal of the American Medical Association titled, "The Iron Triangle of Health Care: Access, Cost, and Quality" reflected that any health care system can only optimize two of the three elements - quality, access, cost.  A health care system which provides the finest quality and best access cannot do so without raising costs to unaffordable levels. An inexpensive health care system available to all cannot do so without sacrificing quality. The iron triangle of health care was introduced to me during my medical school training in the 1990s. Like many others, I simply assumed it was a fact. An immutable law. A fixed certainty that could not be altered any more than gravity.

What if this iron triangle isn't a fundamental truth or law? Why don't other industries have their own iron triangle? Is health care really different than aviation or computing?  Asking this simple yet basic question is something medical students and doctors don't ask. Fortunately, this was not the case for Harvard Business School Professor Clayton Christensen, author of the Innovator's Prescription. His book not only details the theory of distruptive technologies, but also how companies who do "disrupt" the incumbent companies and the status quo are the ones that ultimately provide goods and services which are more affordable, more accessible, and of higher quality. Might there be analogies for health care? Professor Christensen highlights aviation and computing as two examples.

Commercial flight for the masses was not a realistic possibility over a century ago when the Wright Brothers navigated their winged contraption in Kitty Hawk. Even decades later, as epitomized by Pan-Am in the 1960s, air travel was for the affluent and a special event. At that point, air travel was not accessible or affordable for the general public. Yet, in the 1970s, a Texas start-up known as Southwest Airlines provided discounted travel to the general public by offering low fares, no amenities, and a point to point service rather than hub and spoke system.

And traveling by air was never the same again.

Now, more people travel by air than anytime in history with unparalleled safety. More accessible. More affordable. Higher quality.

Computers had a similar beginning evolving from a product where only available to a few due to cost and complexity of the systems to now where computers are affordable, ubiquitous, easy to use and of even better quality than the past. One of the first computers in the 1940s, was Eniac, a huge and expensive mainframe computer which was not reliable, extremely complicated, and accessible only to academics. Years later, the general public typically accessed these mainframe computers at work via technicians. Access was limited. It wasn't until the late 1970s that desktop computers appeared. Hobbyists and others, like Steve Jobs, built computers which were less expensive and underpowered compared to the mainframe computers, but they were more accessible to the general public. It wasn't until many years later that subsequent computers became more affordable, more powerful, and more accessible in the form of laptops, netbooks, and now smartphones and tablets. More people had access to computing because the products were more affordable and of even higher quality.


And computing was never the same again.

Based on Christensen's model, we can predict that health care will indeed break the iron triangle and demonstrate it is not a law but an observation. The question is who will lead these changes? Insurers? Doctors? Patients? Entrepreneurs?


Our next generation of doctors must be trained in other disciplines outside of health care. We must collaborate and accept other ways of looking at the same challenges through the lens of other disciplines including business school. Yet, there is a loathing for this. There is the belief that health care is different. Yes, we can continue to talk about the iron triangle of health care and accept that as a reality.

We can also say no. The iron triangle is not a law but an observation. We choose a different path.

The truth is that this is the most exciting time in health care with the intersection of better medical understanding, the availability of technology, and the best and brightest minds working on the issues of better quality, better access, and lower costs. As doctors and educators, it is our job to make sure the next generation is equipped with the right mindset to team with others. If not, others will define the future of health care.

This is what worries me the most.

Required Reading for Medical Students, Interns, and Residents.

I have had the privilege of working at an organization which is actively improving the lives of its members and also was mentioned by the President as a model for the nation.  Over the past few years, I have also demonstrated to first year medical students what 21st century primary care should look and feel like - a fully comprehensive medical record, secure email to patients, support from specialists, and assistance from chronic conditions staff.

But as my students know, there are also some suggested reading assignments.  I'm not talking about Harrison's or other more traditional textbooks related to medical education.  If the United States is to have a viable and functioning health care system, then it will need every single physician to be engaged and involved.  I'm not just helping train the next group of doctors (and hopefully primary care doctors), but the next generation of physician leaders.

Here are the books listed in order of recommended reading, from easiest to most difficult.  Combined these books offer an understanding the complexity of the problem, the importance of language in diagnosing a patient, the mindset that we can do better, and the solution to fixing the health care system.

Which additional books or articles do you think current and future doctors should know?

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer
Balanced and thoroughly researched, this book illustrates how the failings of our healthcare system are more complex than simply claiming that insurers are greedy and malpractice insurance premiums are too expensive.

Patients with the same illness are getting more costly medical care in certain parts of the country but actually do worse. The amount of medical care delivered is driven by the number of specialists, hospitals, and technology available in the community. The more doctors and hospitals add new services and technology the more likely those expensive services are used regardless of whether patients need it but because the providers can get paid for it. When organizations and committees try to set up guidelines or do research to see if current therapies are effective, special interests and politics kill the initiatives.

Hospitals focus on generating more business in departments which are profitable, like oncology, with newer buildings and the latest medical equipment so that they can afford to run emergency departments which continually lose money. Doctors and patients are enamored with the latest treatments and interventions which often are far more expensive, aren't better than existing therapies, and like the case of bone marrow transplant for metastatic breast cancer patients, are more lethal.

The pharmaceutical industry is intimately linked to doctor education and invariably influences which prescriptions are prescribed and market prescription medications as easily as consumer companies promote common household products. It is money not science that drives the healthcare system.

The author believes that solving the dysfunctional healthcare system requires that doctors and hospitals align themselves into integrated healthcare organizations like the Mayo Clinic, Kaiser Permanente, and the Veterans Health Administration. Unfortunately, however, because she makes such a compelling case of how each of the various providers and businesses each have a financial self interest to keep the current system going at the detriment of patient care, it is difficult to see how the transition will occur, if ever.

How Doctors Think
Fascinating read and written in the same spirit as Malcolm Gladwell's Blink. Dr. Groopman investigates how doctors make misjudgments and misdiagnoses because of their failures to understand and acknowledge cognitive limitations and errors in thought that affect all of us and are unbeknownst to us. He feels that if doctors take a step back, are introspective and insightful about these deficiencies and take appropriate steps to minimize these problems, we can be better clinicians. The doctors he profiles are truly inspirational, remarkable, and masters in their fields, not only because of their medical knowledge, but because of their recognition of what it takes to be superb people and clinicians.

If there is an area of disagreement, then it is the fact that Dr. Jerome Groopman suggests that the pressures of managed care and inadequate time are the cause of many of these cognitive errors. Yet, he never actually proved this in the book. He never showed that doctors were more likely to make the correct diagnoses in an era with fewer time constraints. In fact, he laments that doctors in training, where he teaches at Harvard, don't know how to think and then realized that he hadn't be trained how to think either over thirty years earlier (and hence the reason for his investigation and this book). He claims that quality of medical care shouldn't be simply defined as whether or not a patient with diabetes has his blood sugar checked routinely, yet Dr. Groopman also doesn't acknowledge that the major reason the United States ranks last in the world in keeping people healthy is because the quality of care delivered never was measured as carefully as it is today. Research shows that 80,000 Americans die prematurely (twice the number of breast cancer deaths) simply because the right preventive care wasn't delivered. Had the nation adopted those health insurance plans, hospitals, and doctors, who performed at the top 10 percent of providing this care, these individuals would be alive today. How do they do so well? It is because of implementation of systems that promote excellence.

As a practicing primary care doctor I understand the concerns of my colleagues of showing and proving that they are doing what they say. But we all know if you don't measure something and then re-evaluate it, how do you know if you are doing better? If anything, Dr. Groopman seems to suggest that medical care would be better if doctors didn't have to prove that they performed these metrics to the level of what the evidence shows to be effective even though other industries like financial services, manufacturing, and the airline industry do so rigorously to maintain their high levels of reliability, consistency, and safety.

Although he encourages patients be advocates for themselves, to ask questions, and how to slow a doctor down and think more clearly with certain comments, from his own examples it is clear that it isn't easy to do and frankly somewhat intimidating.

If there is a lesson to be learned, then it is that as doctors we need to understand that our thought processes can be clouded by emotions and can be limited simply because we too are human. To overcome this problem, which affects all of us, we need to be deliberately thoughtful and systematically introspective when caring for patients. As a practicing primary care doctor, I believe that we, not the patients, bear this responsibility and that I hope doctors in training are being taught this routinely in this country and that others welcome the opportunity to do better. While it should be a required reading assignment for medical students, interns, residents, and practicing physicians, better thinking doctors alone aren't going to improve healthcare quality in the United States.  Dr. Groopman's subtle suggestions that they might are simply his error in thinking and his inability to remain open-minded.  The world he trained in is far different than the world his trainees are about to enter.


Better: A Surgeon's Notes on Performance
A fascinating and quick read.   In each section there are plenty of inspiring stores about doctors making a difference. Dr. Atul Gawande, a general surgeon at Brigham and Women's Hospital and staff writer for the New Yorker has keen observation and insight to make single stories demonstrate not only the failings of our healthcare system but also the solutions to them because of individuals asking questions on how to do better. Ultimately, one of the questions he asks is how can doctors and hospitals be positive deviants? How does one become a positive deviant or an outlier that pushes beyond convention and advances patient care to new levels?

He gives examples of how over four million children need to be vaccinated in Northern/Southern India in three days to prevent a large polio outbreak. An immunization rate of less than 90 percent would be considered a failure.

Dr. Gawande talked about the evolution of obstetrics. After a damaging report in 1933, the specialty consequently committed itself to standardizing childbirth ensuring that with the new medical knowledge that it was applied consistently and routinely throughout the country. As a result maternal death in childbirth fell 90 percent from one in 150 in the 1930s to one in 2000 by 1950s. With continued innovations and the commitment to do better, the chance of a woman dying in childbirth is less than one in 10,000 today.

There are plenty of amazing examples that you don't have to be a doctor to relate on how truly inspirational these individuals are in times when the stakes could not be higher - life or death.

Until our healthcare system improves to its full potential as Dr. Gawande challenges us to do, unfortunately will always remain benefiting those who are insiders and harming those who are not. The real question is which one are you?  This failing is part of the reason for the rise of the empowered patient movement.


The Innovator's Prescription: A Disruptive Solution for Health Care
The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it. The authors, respected Harvard Business School (HBS) professor, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School, and another doctor and graduate of the MBA program at HBS have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

Physician Autonomy, Professionalism, and Protocols – Mutually Exclusive?

Doctors are professionals.  But are doctors cowboys or pit crews?  Recently, physician writer, Dr. Atul Gawande, spoke about the challenges for the next generation of doctors in his commencement speech titled, Cowboys and Pit Crews, at Harvard Medical School.  Gawande notes that advancement of knowledge in American medicine has resulted in an amazing ability to provide care that was impossible a century ago.  Yet, something else also occurred in the process.

“[Medicine’s complexity] has exceeded our individual capabilities as doctors…
The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to “protocol” the MRI.”

Despite all of the advancements in medicine, the outcomes and consistency in treatment and care are not as good as they could be.  Doctors are not doing basic things.  The fact that Gawande, author of The Checklist Manifesto, spoke at one of the finest medical schools in the country indicates how much more the profession needs to go. 

“We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.”

So what is the issue?

Doctors usually bristle when facts of failure are mentioned.  When solutions are offered, a variety of reasons of why they won’t work often occur.  Doctors deal with patients and illness.  Medicine is different from other industries like aviation or auto manufacturing in their experience with providing a highly consistent and reliable service or product.  In many ways, this is true.  Patients are unique in their genetic makeups, personalities, backgrounds, and experiences.  Yet, the understanding of many illnesses has evolved to the point that doctors understand how to prevent, screen for, and treat these maladies which often afflict patients in similar ways.  When understood at this level of detail, this knowledge can be codified into protocols and workflows.  As research studies demonstrate what works and what does not, these can be refined further.  Analysis of medical errors borrow the same processes and tools from other organizations dealing with complex systems to determine underlying problems and more importantly solutions to avoid similar outcomes in the future.

The creation of standardized workflows, checklists, and protocols causes doctors to bristle even more.  As Gawande notes, the training of doctors today is essentially unchanged from generations ago which valued physician autonomy.  When asked to follow protocols, doctors often feel this freedom to practice medicine is threatened.  A natural tension exists between physician autonomy and adherence to protocols.  Many will argue that the two are mutually exclusive.  Both, in fact, can co-exist only if we look at the problem through a different lens.  It is about the difference between what Professor Clay Christensen, Harvard Business School professor, and author of the Innovator’s Prescription, calls intuitive medicine and precision medicine. 

It is also about professionalism.  Are doctors professionals or cowboys or pit crews? 

What Professor Christensen refers to as intuitive medicine is essentially how the public and doctors view themselves.  As a result of the medical training, history, and tradition, doctors are thinkers.  Patients present themselves with a set of symptoms or signs that they want doctors to solve.  Because the body only has a certain limited number of ways to manifest an illness (note that for a dermatologic disorder, the skin turns red and can blister due to a burn, drug rash, autoimmune disorder, or contact dermatitis), clinching the right diagnosis required doctors to ask questions, think, use pattern recognition, and experimentation.  Until the relatively rapid learnings over the past century, doctors did not understand the specific mechanisms, pathophysiology of diseases, or the appropriate treatments.   

An example of intuitive medicine was an illness that humbled American medicine just three decades ago.  It afflicted mainly young gay men.  Aside from the observations of a low T cell count and unusual opportunistic diseases affecting these patients, doctors were at a loss of what to do.  How did the illness occur?  How was it transmitted?  How as it treated?  The fear among the public was palpable.  During that time, doctors tried a variety of treatments that invariably failed though through some experimentation and observation, some patterns began to emerge.  The reasons for a few successes became better understood when HIV was discovered and doctors had a better understanding of AIDS.  As a result, the course of illness and then the development of therapies, treatment, and prevention programs occurred which now allow individuals with HIV to live productive lives.  

When scientific understanding of maladies becomes so clear that prevention, screening, and specific therapeutic options can be written down into steps, protocols, and workflows, Professor Christensen refers to this type of medicine as precision medicine.  Many medical problems, like diabetes, are in this category.

The pathophysiology of diabetes is known.  There are two types of diabetes, insulin dependent and non-insulin dependent diabetes.  The degree of blood sugar control can be determined with a simple blood test, HgbA1c.  If a patient has insulin dependent diabetes, the treatment must begin with insulin.  For non-insulin dependent diabetes, treatment can often start with weight loss, physical activity, and dietary changes.  Prescription medications, like metformin, and then later glipizide can be added in a stepwise approach based on a specific protocol should an individual patient’s blood sugar control require it.  The fact that the understanding of diabetes and development has occurred over the past few decades has benefited Professor Christensen greatly.  He has insulin dependent diabetes.  Had he been born a century ago, he would not have lived very long as insulin was not discovered until the early 1920s.

Yet, there are some areas in diabetes research which continue to evolve.  Intensive blood sugar and blood pressure control in patients with insulin dependent diabetes was found to decrease the risk of complications and death.  It was assumed and extrapolated that similar treatment would also benefit those with non-insulin dependent diabetes.  Recently studies have shown that older patients did not benefit and perhaps were harmed with this level of treatment.  As a result, the guidelines have changed.

Although the protocols and guidelines are good, they are not perfect.  They are only as good as the research available at that time.  They continue to be refined.  They are not static.  It is this element that opponents of using precision medicine shout out words like “cookbook medicine” which have significant negative connotation.  This simply denigrates the hard work and research that has allowed an illness to move from the realm of intuitive medicine to precision medicine.  The fact that these protocols are not perfect, should not be a reason not to use them. 

At the heart of being a professional and consummate physician is the knowledge and wisdom to understand when a patient’s illness or treatment of a condition fits a known workflow or protocol and when it does not.  The very best physicians follow procedures meticiously and thoughtfully whether placing a central line using the five critical steps as outlined by McArthur grant recipient and John Hopkins critical care specialist, Dr. Peter Pronovost, to eliminate risk of infection or taking seriously a surgical timeout to avoid wrong site surgeries.

Too often doctors will argue that blindly following protocols infringes on their autonomy.  That is true.  Blind adherence is a problem.  However, passively going through the motions is equally as disasterous.   Life saving treatment isn’t rendered.  Screening tests not offered.   Preventable medical errors still occur.  In November 2010, only six months before Gawande’s commencement speech, a wrong site surgery case was prominently profiled in the New England Journal of Medicine.  It occurred at one of the nation’s most prestigious hospitals, Massachusetts General Hospital.

In the end, it is the mindset of physicians which matter.  We aren’t cowboys.  We aren’t pit crews.  If analogies must be made, then we are like the pilots in flight crews who are professionals and despite the complexity of their roles provide ultrasafe travel.  Doctors are professionals.  It is what the public expects.  Using protocols, checklists, and standardized workflows are just as important as refining them to be even better.  Knowing when not to apply them, is just as vital as ensuring that those situations where they do apply that they are done - every patient every time.

Our patients deserve better.  We can and must do better.

The Rise of Desktop Medicine -- Wrong Terminology, But Right Thing to Do

A recent NY Times article, the Rise of Desktop Medicine, highlighted the use of technology in accessing information (desktop medicine) and how doctors were spending less time with patients (bedside medicine).  Many doctors were concerned about the change and longed for the old days.  Yet, the reality is that with more medical knowledge, doctors must retrieve information from clinical trials, calculate risk of heart attack or osteoporosis, rather than rely on intuition, particularly when data exists.

My biggest problem with this article really was with the term desktop medicine.  I don't like it.  Certainly over the past few decades, our understanding of certain illnesses has become more precise, the interventions and treatments more clear, and therapies more evidence based (precision medicine).  Other illnesses, however, still continue to be more challenging and determining the correct course of action less clear (cognitive or intuitive medicine). 

Precision medicine, a term used by Harvard Business School Professor Clayton Christensen, has simply occurred at the same time computers and the ability to rapidly access information developed.  Imagine if medical science knowledge had evolved but that there was no infrastructure or technology available to retrieve information like clinical trial outcomes quickly.  Doctors would still be treating patients based on intuition rather than science completely oblivious to the latest knowledge.  Research has shown it takes 17 years before outcomes from research studies become commonly practiced in the community.

No desktop medicine isn't the right term to describe the phenomenon in medicine.  It implies doctors are simply indentured servants to computers and technology.  Nothing could be further from the truth.  Generations ago, doctors had few tools and treatments.  When people developed pneumonia, we could do nothing but wait and hope because antibiotics were not discovered yet.  We simply comforted individuals and families.  Many people died.

Today we have more tools, more treatments, and a better understanding of many, but not all illnesses.  To say this additional knowledge and the ability to retrieve this information somehow erodes the doctor patient relationship is incorrect.  We can still be caring and use our technology to access information to make the care of the patient in front of us more precise and personalized than ever before.

No, the terms desktop medicine and bedside medicine are incorrect because they provide the wrong type of connotation.  The former term implies cold and impersonal.  The latter term suggests humanity and comfort.  Better terms with less emotional attachment would be precision medicine and intuitive or cognitive medicine.

I'm a big fan of the art of medicine and bedside manner.   I also love how my computer allows me to make care more convenient and more personal. 

The next generation of doctors must be experts at both bedside manner and using the vast knowledge of medical science to make care precise in areas we have good understanding.  For illnesses where we don't, we still do what we did generations ago, comfort and heal. 

No computer will ever replace that.

Why This Primary Care Doctor Loves his Electronic Health Record

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don't improve outpatient quality.  The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and "doubt [the] argument that the use of EHRs is a "magic bullet" for health care quality improvement, as some advocates imply."

This should surprise no one.  Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes?  Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn't seem to improve outcomes on 20 quality indicators.  First, it isn't clear that the CDS implemented across the various doctors' offices and emergency rooms actually addressed the indicators studied.  Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007).  The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality.  Whether this can be scaled to the national level is the question.

In other words, it isn't just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections.  As most people know already, there is not typically an appropriate antibiotic to use for a virus.  It's a virus.  It does, however, take good bedside manner to inform and educate an ill patient!

As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I'm incredibly lucky.  In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to.  CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time.  It is a safety net.  Understandably some EHRs aren't that good, the CDS is clunky, and certainly the one I use is good, but not perfect.

The real issue isn't finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done.  Indeed, to get into medical school, one has to be self-motivated, persistent, and determined.  Why on earth would we need a computer to help us?

Frankly, because it makes us better doctors.  CDS frees up time and mental energy.  I don't have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia.  Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen. 

Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don't fit any protocol (cognitive medicine) because science hasn't evolved to that level of understanding.  I'm a big believer in the history and physical exam and how the use of HIT can make care more personal.  Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen.  Instead of hunting for lab work in a paper chart or trying to find a specialist's consultation, I can access the information I need rapidly and focus on the patient in front of me.


Sadly, however, many doctors don't feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate.  It might also be, however, our training and tradition which limits us from improving.  If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better.  We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande's New Yorker piece, the Checklist.  Because, really, CDS is essentially a checklist.

In the situation where a patient doesn't fit CDS, then we get to do what we do best and that is use all of our training to get a patient better.   HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before.  In the end, that is what patients really want.

This is why I love my EHR so much.

The Best Book on Healthcare Reform (or Surviving It)

The best book on healthcare reform or surviving it is The Innovator's Prescription: A Disruptive Solution for Health Care .  The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors, respected Harvard Business School (HBS) professor Clayton Christensen, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School Jerome Grossman, and another doctor and graduate of the MBA program at HBS Jason Hwang avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it.  They authors have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

Book Review - Innovator's Prescription: A Disruptive Solution for Health Care

Brilliant. Far and away the best book on health care reform.

The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it. The authors, respected Harvard Business School (HBS) professor, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School, and another doctor and graduate of the MBA program at HBS have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

For those trying to navigate the increasingly frustrating, confusing, and expensive health care system as it current exists, Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System would be the perfect guide book.