My outside knowledge is that a medical facility focuses on: diagnosis, confirmation of diagnosis, selection of treatment along with annotations about EXCEPTIONS to standard treatment, finally actual treatment. I'd like for doctors to focus more on the keen observation and decision parts and would not mind automated transcription of doctor / patient interactions to be reviewed and possibly have a summary forward (but not replacement of actual data) added by other staff. That might be an opportunity to hire/train other types of staff and gain experience in a more concrete way; much like the source article wants to make it easier for potential experts to grow in to a job.
If there's a typical outcome given an input it's important to document the decisions that affected the selection of non-generic courses of action - exceptions are things that should be known in the future. That's something that any worker should do.
The NTSB, as seen in a different recent hacker-news linked article, has excellent postmortems, even for incidents which only came close to being disastrous. A cascade of failures and lack of good decision processes seem to be the typical cause and review with recommendations on how to prevent them from occurring in the future is good. An honest mistake or poor circumstances for otherwise good people are worthy of overlooking and avoiding in the future. Lack of training can be identified and refresher courses or other supplementary training can improve the situation for everyone. Much like making sure someone is addressing problems in their job and growing to accommodate the required work.
Though there might be a bad fit for a job; either someone not able to do the expected work of an individual in that position, a job that's poorly defined and/or not broken up in to manageable units of work, or a worker that is a bad actor to some degree. All of those defects are situations that review and recommendations for remediation should address and resolve.
In your specific case, I believe having a single payer system would improve the outcome related to the above considerations. Affected individuals would still be covered by 'the system', good doctors would not be burdened by specific negative outcomes that happened to occur under their care, and bad workers of any type would be removed.
The actual outcome of individual patients shouldn't factor in to compensation. However addressing that in detail is clearly off the main topic.
I think it is both ethical and practical to recognize and classify cases that are bad fits for a given worker and to attempt to route them to someone that is a proper fit; while providing the best intermediate care and transition possible.
Also of note is that for a 'single payer' system the costs SHOULD be divorced from the actual treatment; though might be a considered criteria when a given standard of treatment is selected.
The patient history we track isn't a literal transcript: it's a transcript of what we find pertinent from our clinical interview and observations. The word "pertinent" there is key; it's intimately and inseparably attached to our decision-making process and diagnostics. Think of it as a persuasive essay. The facts and the deliberation are what a medical historty is, not just a list of data. Med students spend half of med school learning the very basics of this.
> That might be an opportunity to hire/train other types of staff and gain experience in a more concrete way; much like the source article wants to make it easier for potential experts to grow in to a job.
In learning hospitals, we already have residents and med students doing this. And then an attending will come and do it again, because we're better, and this is a learned skill built around our clinical acumen, not a literal transcription.
> If there's a typical outcome given an input it's important to document the decisions that affected the selection of non-generic courses of action
The combinatorics of medicine are too huge for "typical input." That said, we justify all of our decisions, so that someone reviewing our actions can decide whether our behavior - the outcome - was justifiable given the input. The "reviewer" tends to be someone in our own specialty, though - replacing this with something standardized and codified would require, literally, encoding the entirety of medical reasoning. It's a bit beyond modern EMRs.
> The NTSB...
We have what are called "morbidity and mortality conferences." If something goes to shit, the doc responsible gets to take the stage in front of his and all related departments next week, and explain the entire course of the medical episode and the decisions taken at each step, while being monday-morning quarterbacked by every doctor they're even vaguely familiar with. The episode is also forward to Quality Improvement, which is a hospital-led group looking to address systemic and process errors. And, lastly, malpractice suits are the final inspection.
When docs fuck up, there isn't a shortage of post-mortem. None of that does anything to shield physicians from malpractice liability.
(An exception: if you operate in a FQHC - federally qualified health center - for the underprivileged, and you maintain a QI program that meets government standards and audits, the government assumes your facility's liability risk. But physicians are still fire-able at the end of the day as part of the QI process, so the incentive for Cover Your Ass medicine remains.)
"Bad Doctors" are a rarity, in my experience. What is more an issue is "doctors good enough to practice good medicine under modern time constraints, and those that aren't." Not everyone can manage a complex patient in 3 minutes. In fact, most can't. But with everyone squeezing down hard on reimbursement, that's become a necessity. No one wants to pay for the time that good care requires. So, docs default to shotgun medicine - throw all the tests at the patient so you can't be accused of overlooking something, and hope that something comes back unambiguously positive. Next patient.
> In your specific case, I believe having a single payer system would improve the outcome related to the above considerations. Affected individuals would still be covered by 'the system', good doctors would not be burdened by specific negative outcomes that happened to occur under their care, and bad workers of any type would be removed.
I think I should clarify what a single payor is. It's often abused in popular literature to mean something like "government monopoly on healthcare." It's more literal than that, though: it's a single payor. So that can mean things like:
a) A government monopoly on healthcare, where all healthcare facilities and providers are owened by the government, paid by the government, etc. HC is distributed as a utility, and people assume it is covered by their taxes (UK) or they pay a nominal fee (Canada, if I'm not mistaken).
b) Government monopoly on health insurance, but healthcare facilities and providers remain private competitive entities. Healthcare provision remains fragmented as a competitive market, but at least these facilities can expect uniform negotiations and documentation across all their patients, since they're all coming in with the same insurer. Patients expect their care to be covered by their taxes, premiums, or some combination of the two. This is closest to "Medicare for All."
c) Regional monopolies on health insurance. As per "b", except that inter-state entities continue to see some heterogeneity in payors. This regional monopoly might be governmental (e.g., Medicaid For All) or private (such as areas where only one private insurer is available.)
None of these things change the liability landscape directly, although in "a" malpractice liability is usually assumed by the government as hc providers are employees. This doesn't eliminate CYA concerns, but does shift them from "do everything the patient wants, whether or not it's best for them" to "follow local policy and guidelines, whether or not it's best (for the patient)."
> Also of note is that for a 'single payer' system the costs SHOULD be divorced from the actual treatment; though might be a considered criteria when a given standard of treatment is selected.
Why is that? Regardless of who the single payor is, they have budgetary constraints. The appetite for healthcare is infinite compared to resource inputs. Someone is going to be squeezed to make those resource allocations. Currently it's the physicians, but if not physicians, someone else.
* Everyone is covered by one pool
* The pool is funded externally
* absolutely no incentive to defer detection
* absolutely no incentive to defer treatment
* absolutely no incentive to defer care
* because everyone will be covered by the same system in the future.
* Competition can still occur as far as offering services /to/ the pool.
I'm going to have to give my response in a couple of posts, since HN says it was too long.
> My outside knowledge is that a medical facility focuses on: diagnosis, confirmation of diagnosis, selection of treatment along with annotations about EXCEPTIONS to standard treatment, finally actual treatment
The first thing to clarify is: there are a number of different types of medical facilities, ranging from private primary care to massive, regional specialty care hospitals, and the modifications to the above really depend on what type we're discussing. I'll pitch my answer to small-to-mid-sized secondary care (bread and butter specialty care like cardiology; general surgery, some onco surgery; little or no sub-specialty care) because that's the most commonly encountered facility. That's with the caveat that, again, the answer to that is different from other facilities (e.g., your family care practice) that are just as important to discuss.
Your list of things facilities focus on is correct except for your idea of annotations of exceptions. Our documentation focuses on the entirety of the patient encounter, all of the physical and laboratory exam findings we consider pertinent, our treatment choices, and often some degree of our treatment rationale. Outside observers often think "well, don't you just give a standard CHF treatment to someone with CHF, unless there's an exception?" A large purpose of our standard documentation is to provide an outside observer the chance to recreate how we came to our conclusions regarding diagnosis and the best course of treatment. In short, we document to cover our asses from malpractice.
Second, we document so that the hospital can bill insurers. Insurers create increasingly specific requirements for what must have been done or detected before a service can be provided - and those things must be in our note (or else the insurer assumes it didn't happen), and must be linked in our writing (Patient had finding X therefore we did Y). Increasingly, if one doesn't link it, they argue that they couldn't infer that Y was because of X. (That comes up more with performance metrics - oh, you told the patient to lose weight? We didn't realize that was meant to be an intervention for being overweight. We can't just assume what you mean to be treating.)
Lastly, we document for government and insurer mandated performance metrics. For instance, I need to do a depression screening for all over-65s annually. So, a helpful person working on our EMR built-in a reminder tab - did you do a depression screening today? I have to go through a drop-down to select "No", and then another for reason why ("Already Performed", "Patient Not Eligible", "Patient Already Diagnosed with Depression") about 30 times a day. That's our simplest metric, and one of dozens (because there's not a consistent set of metrics across all insurers.) You're about to suggest a way that this can be automated to suck less. I can suggest that, too, but as you may have noticed, this program is paid for by the hospital, to benefit the hospital's performance with insurers and the government. Physicians aren't the customers. Dev time is committed to making it suck less for us only enough to keep us from storming the hospital with pitchforks and catapults hurling ICD10 printouts.
And, lastly, something I truly didn't understand when I worked in health insurance but I do now: there's absolutely no such thing as a standard patient, plus or minus exceptions. The reason for that is because there's no such thing as "a patient with CHF". There's "a patient with history X, which leads me to believe they have CHF subtype 2C, with complications X, Y, Z, and complicating factors 1 and 2." Good doctors keep all diagnoses provisional, because the evolution over time will absolutely change your understanding of the patient - whether to CHF subtype 1Zebra or because what you thought was Complication Y and Z was actually parallel disease Ampersand. This is why we constantly communicate the story of the patient's history to one another, and why every doc takes their own history. Accepting a diagnosis from someone at hand-off is called a "chart rumor," and making a habit of it is a fantastic way of mis-treating patients. I cannot possibly tell you how many times I've improved patient care by just starting over from zero rather than accepting a chart rumor.
A lot of the documentation is an attempt to create "quality standards". I like that in theory, and it's independent of what kind of payment mechanism is used, but ... docs will have a riot if we're held accountable for final outcomes ("This guy has had 30 docs in 20 years, smokes like a chimney despite my repeatedly trying to get him to stop, and I'm getting my wallet drained because he had a heart attack?").
Alternatively, process measures ("Did you put everyone with high cholesterol on a statin?") kill autonomy, require documentation, destroy nuance (there's a good reason I don't want this patient on a statin) and also calcify medicine (advances in medical knowledge occur faster than Medicare updates its performance metrics).
Unfortunately, "quality care" is also a PR move to cut costs. Create enough metrics over enough things docs have no control over, and a documentation slip-up becomes a good reason to ding us our reimbursement. This documentation is also a way to cut government and insurance budgets: they want the information for their programs, but don't want to pay for anyone to convert unstructured medical notes into structured data. Therefore, it becomes an unfunded mandate plopped onto physician's heads. That's not going to go away, unless all insurance - public and private - go away.
All-cash payment removes documentation because there's no one to be accountable to. There's no central party trying to track your outcomes. But... I like the idea of tracking performance. I like the idea of encouraging quality care. I wouldn't mind if we could divorce quality metrics from centralized payors, and put the cost burden of data entry onto the party using and benefiting from that data rather than physicians.
Some of the paperwork headache won't go away regardless. Primary Care docs spend most of their time doing bullshit paperwork tasks. As often comes up on HN, an employer won't let you bring your own chair to work - unless you get a doctor's note. Family med guys write stupid notes every single day, and it occupies a significant percentage of their workday. It's disheartening, and it's not going anywhere.
Another big thing that's happened is social work. Every issue that society doesn't want to deal with rolls down to healthcare: the homeless, the mentally ill, the uninsured, eventually land in an emergency room. That means we're the central clearing house for social services. Psychiatry - especially ER psychiatry - spend probably as much of their time (or more) networking with social work and the state trying to secure Medicaid and housing for patients than they do addressing their mental health needs. It's work that needs doing, but man is it heartbreaking to train to be a physician just to spend your day trying to arrange housing.
Lastly, even a single payer system has incentives to deny services. That's still a cost borne by the system. Accordingly, docs will still find themselves fighting paperwork battles with the insurer to justify a course of treatment - they'll just be doing it against a single bureaucracy instead of several.