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Can Technology Better Manage Healthcare?

August 22, 2008
by Joe Marion
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Last week, while on vacation, I had the opportunity to experience an example of healthcare up close and personal, as they say. Let me qualify what I am about to address by saying that this may have been an isolated incident. My fear is that it is not, and that is why I chose to write about it.

I should like to describe what happened, and then highlight where I think the system broke down.

While in Florida visiting a 90-year old family member, she managed to slip and fall the first night of our visit. She has difficulty walking and was using a walker at the time. The walker caught on something, and down she went! She complained of soreness but was able to get back up with assistance.

The next morning, she was no better, and she opted to be taken to the emergency department of a nearby hospital – by ambulance, as we were unable to move her. Upon arrival, she was placed in an emergency room bay and attached to vital sign monitors. At some point a nurse came in to take her history, draw blood, and insert additional lines. She was given a pain pill, after initially being told she could not have anything to eat or drink, as she might require surgery.

Eventually, she was taken to Radiology for an X-Ray of her hip, which came back negative, except for a possible fracture of her pelvis. The staff indicated that she would need an MRI, and they were waiting on the physician to order one. Eventually, they came to pick her up for a CT! OK, so they changed their mind and ordered a CT instead of an MRI. About one hour later, she returned. The technologist indicated she refused the CT exam! So much for informed patients who listen to the press regarding dosage issues with CT!

After another two hours, she was finally taken to MR for an exam, and then taken up to a patient ward, where she was kept overnight. All told, over seven hours in the ER!

We were met the next day by a case worker who was to assist us with her disposition. We quickly learned that in Florida (and as I have come to find out, is also true in many other states), as long as the patient is in control of their faculties, they make the final call on their course of action. We had felt the best thing for her would have been a continuous care facility, but when confronted, she indicated she wanted to go home – no surprise there! The case worker indicated that she would take care of making all the arrangements with the proper agencies, and she would be released later in the day. At some point we learned that she could not be released without these arrangements for in-home care.

Needles to say, when she arrived by ambulance back at her home at 5 PM, we were met by the care giver. When the care giver was asked if she was OK with getting up with her several times during the night, she replied “no, I need six to eight hours of sleep at night, and no one said I would have to get up.” She was summarily dismissed, and after another two hours of negotiation with the agency, we were able to secure someone who was willing and able to care for her 24/7. I am happy to report that she is doing better, but still confined to a wheel chair and unable to walk.

Now, for the issues with the process:




What you encountered is mostly a reality across the healthcare delivery system. Technologies do not a system make. So what we have are isolated pieces of technologies and no system.

If we optimise each piece of a process, does it optimise the whole value chain? Unlikely! did I hear you say?

At most ERs 3hrs 30 minutes is a norm for just being admitted and discharged if you had no physical ailment and simply faked getting admitted..

On anything where the diagnosis requires some checks and balances, please keep adding up hours.

In my opinion, its because hospitals are not designed to treat patients. They are designed to do this and that. And that's what they do well.. just this and that.. Each of this and every bit of that is process driven.. Calling it departmentalisation is like using a horse-age example to clarify a space age to hear, and leaving us no wiser for it..

It was a very normal case..
Technology cannot make it any better.. it can improve some results at best.. a better validation, may be..
It is a perfectly reasonable thing to ask for..theoretically.. to realise that you need a revolution..
If a hospital decides to create a patient centric organization, we may not hear about such cases.. As of now the patient is at their mercy!

as you allude to, if no one individual has overall responsibility for the patient from the time they enter an ambulance to the time their "episode of care" is completed, it will be a continual case of hot potato, in which each entitiy is only incentivized to take on the minimal liability possible, while still billing for anything they can think of. Too cynical? Maybe

We've been looking at the CDC's attempt to better understand healthcare delivery through ER data here.

Satish's framing "technologies do not a system make" is dead on. This discussion remind's me of Peter Senge's 'beer game' of a decade ago. When each of the players tried to do their isolated part, the system consistently blew-up.

Satish, Joe and Anthony have each describe a blind man's impression of the elephant and each is correct. But a seven hour Emergency Room visit appears to be normal for Sacramento. But what technology are we talking about? Isn't the real issue economic?
Each of the four hospital systems in Sacramento has a $100+ million expansion program. Despite the emphasis on outpatient medicine, the hospitals are betting they can alter the landscape. The ER appears to fund the expansion.
I see patients who have chest pain who have been to the ER and obtained every cardiac evaluation possible of six to ten hours and then be told, that we are happy to inform you that you have no serious heart disease. They are asked to see their personal physician the next day to transfer liability away from the hospital. When I see the patient my hand goes immediately to the chest where the patient states the pain is and as I press on the costo-chondral junction, (Rib—breast bone junction) they say, "Now that's the pain I went to the ER to have evaluated."
Costochondritis, inflammation where the ribs articulate with the sternum, is a very common musculo-skeletal problem. I see at least several every week and several every month that have gone to the ER with a full cardiac workup and no diagnosis which I make in the first 30 seconds. An ER doctor told me that they couldn't make any money if they diagnosed something in the first few minutes. They and the hospital work by hours and shifts.
A clerk, who works in the ER of one of these hospitals, is a patient in my office. She told me that they are told not to play doctor but to treat every chest pain equally. She states that the average hospital charge for chest pain complaint is $9,000. How else would they pay for the $100 million addition? But the insurance company is able to negotiate their portion down to perhaps one-third but the patient still pays the full 20 percent on the total charge.
The whole issue could be solved in the free enterprise market. In our research, studying 5, 10, 20, 30, 40, and 50 percent co-pays, we've found that a 20% co-payment for ER evaluations reduces all ER visits to the minimum without limiting access or reducing the quality of care.
This was recently demonstrated by a patient who went to the hosp ER for breathlessness without chest pain. She had Medicare and was responsible for the first 20%. She was in mild cardiac failure which resolved on the first dose of IV Lasix. She already had a cardiac ECHO and had good heart function. As they were about to wheel her out for more tests she asked about the cost. When she found out that it was a few thousand dollars more testing, she told them to hold up. She felt better and desired to go home since they had assured her that she did not have a coronary. She said she would be back if she got worse, but was doing very well the next day. She stated that the ER staff seemed very upset over her early departure. She was wondering if perhaps she cut off the cash flow. She was still doing very well when seen a month later.
She said she got out of the ER with a charge of 20 percent of $3500 or $700. She found out that the tests would have gone over $8,000 and she is so thankful she cut if off at $700 copay rather than $1600 copay if she had stayed longer.
A percentage co-pay will bring health care costs under control and make it efficient. Patients who pay 20% will not visit a hospital again that averages thousands of unnecessary dollars a visit and will seek out the best ER with the most efficient care at the most reasonable costs. Any one can make one costly mistake. But no one will make a second costly mistake. Health care cost control occurs with the second if not the first visit. Government cost control occurs after months and years of congressional hearings, debates, political maneuvering, and legislation which more often than not increases the cost.
And patients will no longer brag to their friends, relatives and neighbors that they went to the ER and had $10,000 worth of tests and all was normal and it only cost a $50 co-payment. That beats Mayo Clinic and all the rest for efficiency. Nobody even thinks of the $10,000 additional premium that has to be collected down stream for each visit. Such a raw deal.
Instead, they will go to their friends, relatives and neighbors that they had chest pain which they though surely was a coronary. After an ECG, ECHO, and several blood tests they were assured that they had no heart disease and the total charge was only $1200 and they only had to pay $240. Such a good deal for this kind of re-assurance.
The former will only lead to rationing and the ones that need life saving care will be rationed out of care and may die.
The latter is the landscape is the responsible one that will save American Medicine, the worlds finest and most sophisticated.
To read other cases that continue to make this point, you might sign up at and click on Newsletter.
Sorry, Joe, technology is important but not the answer without the economic answer. Third party health care will never make this more efficient. Just read MedicalTuesday for a few weeks to see that 25 to 40 percent of health care costs would vanish overnight with a percentage co-payment for every item in the CPT.
Del Meyer, MD
Pulmonary Internist