Sunday, August 02, 2009

What Will Tomorrow Bring: Concrete Ideas for Improving Healthcare

I'm sure hard on the healthcare industry (cough, cough, Land that Time Forgot, cough). Call it constructive criticism. But I'm not just full of nay-say. Allow me to offer a few very concrete, actionable recommendations to go with all the high-falutin' principles I've been throwing out lately.

On medical records and privacy:
It goes without saying that medical records must be put online. Period. Now. There is NOTHING technologically standing in the way (see here, here and here for just a taste of what's already out there). That isn't to say that all the rocks have been removed from the road of course. But we're smart, right?
Ideally, one should be able to control which individuals can see which pieces of their health record by setting policies ahead of time. For example, one might say that, in an emergency, EMT staff can see all current health info; hospitals can see more; a radiologist can see less; a pharmacist can only see current medicines and allergies.

At a national level, health data must be irretrievably separated from identifying info and then aggregated for statistical research.
On prescriptions and drugs:

Doctors should write up prescriptions on a secure iPhone/Blackberry/Palm/Android app. This isn't dreamware. The foundations already exist.

Contra-indications, genetic red flags, and bad interactions with other current meds should all be checked automatically via an online service accessing a national database (perhaps run by the FDA?). The doctor should be immediately notified of issues.
Controlled substance notifications and approvals should be automatically taken care of as necessary.
Insurance approval should be automatically collected and the billing process should be launched.
Then, the 'scrip should be sent electronically to my "pharmacy" (this is no more technologically complicated or insecure than direct-depositing a paycheck). I put pharmacy in quotes, because it would bear a closer resemblance to than your the local chemist of yore.
An automatic "broker" looks at my urgency as well as current drug supply to determine where the order gets filled.
Urgent orders go to the closest local drug warehouse which currently has the drug in stock. Non-urgent orders go to a national fulfillment center. Again, think ... come to think of it, maybe we should just let them do it.
In either case, a robot distributes the right number of pills into the right bottles. It then marries that with the right instructions and documents. A human quality control might be performed before the robot packages the whole thing up, and hands it off to the delivery system (either via local same-day delivery or simply UPS).
An email is automatically sent to me confirming fulfillment, and providing links to all the usual legal-ese, warnings, indications, and stuff required by the FDA.
If required by the FDA, a pharmacist should call me to explain the required mumbo-jumbo. If this gives lawyers fits, an alternative would be to provide this info face-to-face before the patient leaves the doc's office.
Then the 'scrip should be put in my medical record, the doc's files, and, anonymously, in national databases available for research. For one thing, this prevents me from double-dipping. For another, it provides drug companies with a much deeper source of usage and efficacy data.
If the 'scrip calls for refills, they should be automatically processed in the same way. Neither the doctor, nor I, nor a pharmacist should have to lift a finger.
On Insurance:
As I said previously, employer-provided insurance has GOT to go! Each individual or family should buy their own plan, based on their own preferences, and considering their own unique situation.

Yes, this means the end of the "one size fits all ... at one price" policies that we get from our employers. That's a good thing, because currently, we're spoiled. All the talking heads on TV keep trying to get Obama to say there will be sacrefice. He chickens out, but I won't. When it comes to your health, you should have to do your fair share. Today, we're just passengers getting taken for a ride. Instead:
    • We see more and more evidence recently of just how bad people are at making certain types of decisions. Specifically, we suck at assessing extremely unlikely events. Inevitably the "won't happen to me" gene kicks in. When the inconceivable happens, we're caught unprepared and confused. Thus, the vast majority of Americans should have catastrophic insurance. Period. No excuses. It should be cheap, and should only cover the really nasty stuff. No pills for sniffles or aches ... it should only kick in once expenses are above, say $15k. With a nice scotch, a good joke, and a pat on the back, Obama could probably convince me to socialize this piece of healthcare, as long as he doesn't go Robin Hood on me.

    • Today, prudent travellers take out trip insurance; prudent SCUBA divers have DAN; hikers (and extreme skiiers) get evacuation insurance. This should be the norm for all health insurance. Smokers should pay more. Skydiving injuries should not be covered unless a risky-activity premium has been paid. Conversely, people who do more than an hour of cardio a week should get a rebate. Triathletes should be damn near free.

    • Folks who prefer one treatment to another should be able to negotiate this with their insurance. For example, someone with terminal cancer should be able to trade. "I'll give up chemo, but ya gotta pay for accupuncture, a home nurse, and a pain clinic." Someone with a blown ACL should be able to say "I want extra PT. In exchange, I promise to follow their advice dilligently and keep the knee in good shape so this doesn't happen again." Someone who injures their spinal cord should have the ability to agree "Let me try this experimental treatment, but if it doens't work, I won't sue, or ask you to treat any side-effects." People who are willing should be able to get treatment offshore if the cost differential is significant.

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