• population health for better good outcomes
• less money
• accountability by patient
• the challenges of change to doctors, nurses and patient
are the common themes and and main challenges for healthcare according to Peter Edlestein, CMO at Elsevier. H&TI met him while he was in Paris on November 9th.
Interview highlights:
« We need to get away from healthcare being the doctor and the patient and talk about populations. Doctor and patient alone, can’t solve the pandemic of diabetes, the pandemic of heart failure, alzheimer’s or cancer ».
« We’re also talking about reducing the costs for care, and finally starting to accept that we must shift some of the responsibility for health and healthcare on the patient ».
» Technology makes care better. But the lack of technology cannot be an excuse for poor care. That’s not acceptable. »
What are the biggest challenges in healthcare today?
Even though there are many individual differences between countries, and in countries like India or China, differences between regions, consistently we see several common themes.
First, we need to get away from healthcare being the doctor and the patient and talk about populations. Doctor and patient alone, can’t solve the pandemic of diabetes, the pandemic of heart failure, alzheimer’s or cancer.
We’re also talking about reducing the costs for care, and finally starting to accept that we must shift some of the responsibility for health and healthcare on the patient.
But, finally, wether you’re in France or in the US, It’s politically risky to tell people they have to take care of themselves. That’s not true everywhere, like in Asia where some countries can just make rules, but that’s not how we function in Europe or North America. Doctors don’t want to be told how to practice. They’re experts they don’t want advice, because we’re actually worried we could be wrong. And I’m a surgeon I understand that.
When did it start ?
It all started in the US with the affordable care act (Obamacare). Why did that happen? The US had already 2 major healthcare reforms that lasted for a few years and went away This one didn’t go away for a couple of reasons:
What use to be only to talk to economists, the cost of healthcare, was suddenly appearing on TV in the newspapers and magazines. And even though my mother doesn’t understand the graphs of percentage of healthcare vs. GDP, she knows it’s up here and everyone tells that 17% of GDP go in healthcare. The government was quite successful in simplifying the argument and saying every hundred dollars that America spend in anything, 17 is for healthcare. People started saying : « that’s way too much! » But then they said, « it isn’t too much because we have the best healthcare in the world ».
And that’s the second reason. It’s not true. We started looking at outcomes for the top 10 diseases, and we were never number one. We often ranked number 50, but we weren’t even close on many things. So it’s like you pay more money for a car that is broken down. Once the public started seeing this, it started to wonder.
In 1999 a famous paper was published by the Institute of Medicine: « To err is human ». It showed that the 3rd leading cause of death in the US for adults are preventable errors in the hospitals. Between 200 and 400 000 Americans die a year at a cost of over 1 trillion $ a year.
And now we know that when countries like France publish that data, if they do, the figures will be the same or worse than in the US.
When this kind of information gets into the public, that they’re paying for things that aren’t good, people gets hurt, it angers and empowers them. That has not happened in every country yet, but it’s happened in Australia where they recently released the annual preventable death rate as 18000 a year with 50000 major preventable injuries. Now the people know. Even China released some of their premature death data.
That’s what led the movement in the US many years ago: there are many problems and it conceptually has to change.
What about Europe ?
Europe is starting to see this, particularly the UK and Spain. What does that mean when you start realizing it? The first thing you do is to look at the system : why are we paying a lot for terrible care ? That’s because the system that’s widely used in the world can be called fee for service.
Let’s take an example: Your father comes to me with a big cancer in his intestine, blocking it. I have to do an emergency surgery that night. I have had a little too much French wine, I don’t do a good job and cause an injury. So now, after the surgery, he goes to an ICU. His third day in the ICU, the nurse gives him a wrong dose of medicine and his kidneys shut down. Now, he is on dialysis. Meanwhile, I have to perform a second operation to fix the mistake I made in the first one. Two weeks later he leaves the ICU, 5 weeks later, the hospital, he is in rehabilitation for 3 months. Would you agree for him that’s bad quality? Of course. Still, I get paid for all that, so does the hospital, I get paid for the 1st operation, I get paid for the second operation to fix my mistake, I get paid for the dialysis because the nurse made a mistake, I get paid for the ICU he didn’t need, I get paid for the rehab he didn’t need.
Let’s backup : He comes in with a big cancer, I do a good job, no errors, he never goes to the ICU, never gets the wrong medication, and goes home in 6 days without rehab. Better quality, costs less.
Backup further :3 years ago, as he’s supposed to, his primary care physician had him a colonoscopy, they removed the polyp, he never gets cancer at all.
It’s like saying, well I can’t afford a Kia, thank god I can afford a Ferrari, because it’s cheaper.
Pay the money to do the right thing, it’ll cost you less and they’ll be healthier.
And the key for that is information. At Elsevier we provide information. A hundred years ago, the only one way to get information was in books, now it’s digital. We’re in the information business, current credible evidence based information.
What about technology?
One of the most common misperception I hear is “yes we have all these different bad care, too many tests, too much money spent, but it’s all going to be ok because we bought an electronic health record system.
In the US we spent billions of dollars 10 years ago on EHRs only to found out they didn’t make healthcare better and didn’t cure cancer. They actually did very little, because they’re just vehicles for information. Technology is a good vehicle but current credible evidence based information is the solution. So if you don’t have EHR everywhere, that’s ok, we have the cloud, we have pencils and papers. EHRs are just better. While you are getting infrastructure, you should still getting information. Stop blaming infrastructure.
Don’t get me wrong. We strongly encourage better technology. The power of EHR compared to print can’t even be imagined. Telemedicine now allows a cancer expert to consult with someone on a remote Island in Asia. Technology makes care better. But the lack of technology cannot be an excuse for poor care. That’s not acceptable.
Don’t put the cart before the horse. Some believe the answer is the technology, and the answer is the information. Technology cannot be longer an excuse to bad clinical care that cost too much.
This about deep reforms and even a cultural changes. How can it be achieved ?
France could do this tomorrow if they chose to do it. But the reality is that trying to change too quickly, making rules overnight, is a mistake. Only I want to see is France start and slowly move forward, and I think you’re ready. People know that something needs to be done.
What is the basis of healthcare reform? value based care, but also a philosophical shift in the model. We need to move away from what we call reactive, acute, efficient care to proactive, out of hospital preventive and maintenance care.
If you get to the basic of healthcare reform in most countries like the US or France, that have many hospitals, the goal is to reduce the number of beds by about 20%. Some say more.
What happened in the US. 10% of all hospitalization in the US are related to the fact that people don’t take their prescription medicines correctly. Half of al Americans on prescription medication don’t take them correctly, it directly leads to 125 000 deaths a year, an cause 289 billion $ . So, if we simply educated and incented people to take their medication correctly we could close up to 10% of our hospital beds. Now, take very heart failure patient and give them a bathroom scale. Take every diabetic and give them the technology to do their glucose. There’s a real ROI, and people are doing better. Why don’t do this ? I’m passionate about it because people are dying.
How do you get the doctors and physicians to use this information ?
In the United States we don’t have orders written by hands. But we use what we call order sets. Order sets say, “ in this hospital, whenever you admit a breast cancer patient, here’s what evidence suggests you should do”. You don’t have to, you can chose not to, but we keep a record of what you do and don’t and we’re allowed to ask you why? You may be right to do differently, but you just have to write it down. “I understand the suggestion, but I use a different dose because I treated this patient before and he needs a smaller dose. It doesn’t replace the doctor. But the doctor cannot ignore the information. The doctors are empowered.
