Doctors are the Problem with Medicine

What exactly is wrong with medicine and how to fix it

Introduction

The title may be a little sensationalistic, but we will show that the training that doctors receive and the way they solve problems are holding back forward progress in medicine.

The Problem

Doctors are great at what they do and some of the most highly educated people on the planet.  It takes between 11 and 17 years to train to become a medical doctor.  When a practitioner is presented with a patient, he or she starts afresh with the process of wellness or healing.  Like the fictitious M*A*S*H character Maj. Charles Emerson Winchester III stated, “I do one thing at a time, I do it very well, and then I move on.”  This linear form of thinking gives the practitioner blinders that help him or her screen out the distractions of the world but lead to “workflow” thinking.  That means that we complete each step in a process then move to the next until we are done.  This works great in medicine, or if the process requires one person.  If Ford used this workflow mentality, they would produce a single F150 for each employee every year, it would have horrible quality because it was built by a single guy with no expert knowledge of some of the parts and processes and cost a million (or more) figurative dollars.  This exact thing is the subject of Dr. Eliyahu Goldratt’s 1984 book “The Goal” where he introduces The Theory of Constraints (TOC).

What we should be thinking of is dependencies.  To perform a procedure we need a place, a patient, a diagnosis, and any supporting equipment and staff.  These are dependencies.  Ford needs pistons, engine blocks, brake rotors, seats and body panels.  The production of these parts happens independently and simultaneously, not linearly.  Thusly, Ford can sell an F150 for as little as $38,000 and produce three quarters of a million of them every year.

That really doesn’t tell us much, however.  How does this linear thinking hold back medicine?  Was our fictional Dr. Winchester correct?  We don’t think so.  Doctors are great at medicine, but can’t be let loose to manage a practice, or the business of medicine in general, clearly.  Let’s examine a few things that really aren’t related to treating patients but that are integral to the function of medicine that prove this linear thinking is the problem.

Specialties

Because of this linear thinking, we end up with medical specialties.  Instead of looking at the commonalities in all branches of medicine, we look at the differences.  When we are using paper charts, that doesn’t matter.  But paper charts get destroyed, lost, need a support staff to find and maintain, and of course aren’t portable.  We all know the pitfalls.  When we move to a demonstrably better system of electronic medical records, we just mimic the paper “workflow.”  Remember that workflow is our enemy and the product of linear thinking that is holding us back.  Until now, nobody has thought about the commonalities of specialties instead of the differences.  What exactly do we need in a medical record?  

1. Patient Identification Information
   This is the foundation of every medical record- the simplest yet defining component. It includes basic yet crucial details such as the patient’s name, date of birth, gender, contact information, and identification numbers.  After all, one needs to make sure they’re treating the right patient!
2. Medical History
   A patient’s medical history is an invaluable resource for healthcare providers. This component includes information about past illnesses, surgeries, allergies, and pre-existing conditions. This helps practitioners recommend treatment plans that don’t cause any complications/reactions due to existing conditions.
3. Medication Information
   All current prescriptions, over-the-counter medications, dosages, and any past medications that have been administered to the patient, are listed here. Amongst the crucial components of medical records, this prevents dangerous consequences and ensures adherence to a treatment plan.
4. Family Medical History
   Family history helps anticipate potential health challenges that may arise in the future. It helps identify risks for conditions like diabetes, heart disease, or certain types of cancer so early screenings or preventive measures based on familial trends can be recommended. 
5. Treatment History
   A part of  medical history, treatment history focuses on past treatments, surgeries, and hospitalizations. Such components of a medical record informs future care decisions and avoid unnecessary procedures. For instance, a patient with a history of failed chemotherapy treatments might be guided toward alternative therapies.
6. Lab Results and Diagnostic Reports
   Lab results and diagnostic imaging reports (like X-rays, MRIs, or blood tests) are among the components of medical records that form the evidence-based core of clinical decision-making. These help track the progress of treatments and detect any complications that may require attention.
7. Consent Forms
   This section stores signed documents that confirm a patient’s understanding and agreement to specific procedures or treatments (like surgeries/clinical trials). It protects both the patient and the healthcare provider, ensuring everyone knows what’s happening and the risks involved.
8. Progress Notes
   These are the ongoing narratives of a patient’s care, written by healthcare providers after each interaction or treatment session. Progress notes reflect updates on the patient's condition, responses to treatment, and any modifications to care plans.
9. Immunization Records
   A part of the vital components of medical records, this section tracks all vaccines a patient has received, from childhood immunizations to travel vaccines. These help avoid over-vaccination, and enable timely interventions while aiding in population health management. 
10. Financial and Insurance Information
    Though not directly tied to clinical care, this component is crucial for the operational side of healthcare. Details about a patient's insurance coverage, billing history, and payment arrangements. ensure that treatments are billed correctly, insurance claims are processed smoothly, and patients are not blindsided by unexpected costs.

Notice that nowhere in here is a specialty mentioned.  If, then, we can include these into a common format and include a way to document the things that are peculiar to the specialty, then we have eliminated the linear, workflow thinking.  This, then, makes maintaining a medical records system a single process, not a “make one for each specialty” process with 135 or more different pieces of software like current medical records vendors.

AMA and CPT Codes

First, Codes in general are problematic.  They lead to tribal knowledge and obfuscate knowledge.  It isn’t easy to download a copy of procedure codes that are owned by the AMA.  They want to know what you are using them for and why you want them and will quite literally ask you to schedule a meeting with them so that you can pat them on the head and assure them you aren’t using their codes for nefarious purposes.  That is a problem.  These codes are public domain and should be shared freely.

Second, we all know the old guy in the auto parts store, or whatever other industry that requires a lot of specific knowledge about the subject, that knows the part number for every piece of a Chevy or Ford.  While this is amazing, we can’t reliably produce these people and we probably should not.  This is the tribal knowledge we were talking about earlier.  We can’t run an ad, hire a new guy and have him perform like the old guy that knows that alternator A is exactly the same as that alternator B except the plug is on the other side.  ‘Clocking’ an alternator is beyond the scope of this article.

Third, these codes take on a life of their own.  Ross Dress for Less buys various things from various places and ships them to its retail stores.  The shipping is handled at a distribution center.  The distribution center is partially to house a “Pack Range” which is a collection of boxes representing a store that workers put items in until the box is full, then they put it in a truck and ship it.  The problem is that each store has a code.  The codes are arranged numerically to make them easy to find.  As stores are closed, we get holes in the Pack Range.  As stores are opened, we put boxes, out of order, on the floor.  Yes, there are holes in the Pack Range in which we could put these floor boxes, but we can’t because the ‘code’ for a store can’t be reused.

The conclusion is that we can’t use codes.  We need specialists to maintain and use these codes and that is expensive and making the documentation of a procedure more important than it needs to be Luckily, the people at the National Institutes of Health have produced the Unified Medical Language System (UMLS) that codifies and makes searchable anything you can do to a human body.  If we can use the UMLS in a way that hides these codes, and we can, then we have the beginnings of a solution to this problem.  Additionally, using this to actually document the patient encounter will obviate the need for medical coding altogether.  More on this later.

Clearly, we can see the consequences of this linear thinking.  We also demonstrated a way to avoid these problems as the pertain to medicine, altogether.  We have all the pieces; they just need to be put together.  More on that later, so be sure and read until the end.  

HL7 and Fast Healthcare Interoperability Resources (FHIR)

The HL7 and FHIR problem is similar to code problem.  These are protocols designed to facilitate knowledge transfer between approved medical entities.  Lack of foresight doomed them to fail from the start.  The real problem is that these protocols are designed to solve every eventuality, transfer every kind of medical data, that they are literally unusable.  

First, FHIR is based on HL7.  HL7 is based on channels that define various types of medical information.  That all sounds great, except that no one sender puts information in the same place as any other one sender nor the receiver.  The programming world solved this problem with extensible structures like Extensible Markup Language (XML) and later JavaScript Object Notation (JSON) that are self-defining and can be automatically converted to programmatic objects with no effort.  If we need to transfer a different or new kind of information, we just add a tag, and set the value, there need be no versioning documentation or governing body.  Defining XML and JSON are beyond the scope of this document, but suffice it to say that HL7 is a trainwreck of the first magnitude and is an example of this linear thinking that attempts to solve one problem, albeit very well, instead of solving the class of problems the way a programmer would.

Manual processes

Another problem with linear thinking is that when a new problem is defined, we usually just hire a new person to implement the solution.  The only manual processes in a practice or hospital should be the dispensing of medical care.  We probably want someone to manage the practice and make sure that reports get run in a timely manner, data gets entered and validated, and wrangles patients to the correct spot at the correct time, but really that is about it.  

Workflow and Insurance

The place this all culminates is insurance.  Because of this linear thinking, insurance requires doctor defined medical codes, so we have an entire billing, coding and collections staff looking at patient documentation all day, translating it into codes and transmitting those codes to the insurance company.  The insurance company, in turn, uses manual processes to adjudicate a claim and possibly deny coverage of medical care a doctor has (probably) already performed.  The mind boggles at the amount of wrong-headed thinking that got us to this point where a banker tells a patient he or she can’t have a procedure that a doctor has deemed medically necessary.  Even worse is the cast of tens of thousands that the insurance companies employ to adjudicate and deny payment for medically necessary procedures.  Finally, think of all the big buildings, all the equipment in those big buildings and all the people running that equipment in all those big buildings belonging to insurance companies.  The insured patient pays for all of that, and it is due to this evil workflow/linear thinking.

The Solution

The solution, of course, is to stop this workflow thinking.  We need someone to take a look at the inputs and outputs of the entire process, the dependencies we wrote about earlier.  Once we have these dependencies mapped, with an eye toward who, what, when, where an why (and of course who is going to pay for it all), then and only then can we start to streamline and automate processes.

We at Sentia have done just that.  We started with the insurance company and bubbled this automation up through the practice itself.  What we propose is a new breed of insurance that provides the medical records system to the practice.  This system is not specialty specific, but uses the UMLS detailed above to a universal nomenclature that has already been translated into several languages and includes the approved drug database (RxNorm) and the Value Set Authority Center (VSAC), a repository and authoring tool for public value sets created by external programs. 

This makes writing the records system much more simple and easy to do, and in fact we have already done it, and gives us the ability to pluck procedures performed out of the system and pay for them in real time.  This eliminates all the big building and equipment and people the greedy bankers running insurance companies rely on to run their business.  It streamlines and automates the practice as well. From our article “Ancillary Costs that Drive up the Bill for Healthcare:”

Medical Coding

• The average practitioner spends $20,286 annually on medical coding
• The average patient spends $60 annually on medical coding
• The average patient encounter or visit cost for medical coding alone is $18

Medical Records

• The average practitioner spends $35,925 annually on electronic medical records
• The average patient spends $106 annually on electronic medical records
• The average patient encounter or visit cost for electronic medical records alone is $32

Compliance and Efficacy Reporting

• The average practitioner spends $17,165 annually on compliance and efficacy reporting
• The average patient spends $51 annually on compliance and efficacy reporting
• The average patient encounter or visit cost for compliance and efficacy reporting alone is $15

Streamlining and Automation Savings

 We chose these three cost centers because we believe they are wholly unnecessary.  The total wasted resources per year are $65,830,000,000

• The average practitioner spends $73,376 annually on completely avoidable costs
• The average patient spends $217 annually on completely avoidable costs
• The average patient encounter or visit cost for completely avoidable costs alone is $66

Summation

The legacy insurance companies return about 53% of your premiums as benefits.  Sentia’s health insurance would replace this 47% cost of doing business with a $10 per month subscription fee to manage the data, plus the actuarialized cost of the incurred risk of course.  Here is what health insurance costs as of 10/18 2023

Figure 1 - Insurance Costs

Here is the breakdown of your savings with us:

This does not include the savings that the practice and hospital will see with their own automated processes.

We can cut the cost of medical coverage by half or more.  We do this through automation.  We get to the automation through dependence-based thinking instead of workflow.

Conclusions

We have shown why workflow, linear thinking is the bane of efficiency and the very reason that the cost of healthcare is higher in the US than anywhere else.  We have shown a way to produce better results through dependence-based thinking, leading to streamlined and automated processes.  We have described a system that will produce these better results. We have already built this system and it is in prototype at this very second.  For those of you in the cheap seats, I’ll say that again: we already have this system in prototype and can show it off.  

We have shown a way to reduce the cost of health insurance by far more than half.  Then, we will be not only the cheapest medicine in the world, but also the best.  We already have the best doctors and the best equipment; we just need to implement the above detailed framework to give them all the tools necessary for success.

We have this system in prototype now, fully functioning. 

Contact us here or on our site and we will be happy to provide a demonstration of the fully functional prototype.

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We have built a comprehensive health information system to keep the patient healthy and on the right track with the ability to incentivize healthy living.  Implementing this system should be fairly simple and will completely revolutionize the way healthcare is paid for, saving countless lives.  We have shown a way to use this system to make the best healthcare system in the world also the most efficacious and the most affordable, and a way to move toward value-based care.