EHR adoption rates are picking up significantly, exceeding the most optimistic expectations. Instead of an EHR for every American by 2014, as the President commanded, we will have dozens of EHRs for each American long before that. And in health care, more is always better, not to mention the freedom of choice that comes with having a different EHR in each care setting. Not surprisingly, we are seeing a decrease in health care expenditures taking place in parallel with the uptick in EHR adoption. Following best practices in health care economics research, when two phenomena develop in parallel, the learned assumption is that there is a causality connection between the two. Deciding which phenomenon is the cause and which is the effect is discretionary and commonly based on undisclosed agendas.

It is therefore postulated here that health care expenditures are inversely proportional to EHR usage rates. The following is a rigorous analysis of the mechanisms by which EHRs are reducing health care costs, intended to inform policy makers as customary in most health care related studies, which cannot be completed, or published, without a salient recommendation of interest to policy makers.

Productivity Optimization – Numerous carefully estimated anecdotal studies consistently show that introduction of an EHR in ambulatory practice can reduce provider productivity by 50% or more. This directly translates into 50% (or more) savings in health care expenditures for office visits. Unfortunately, the same studies also show that in most cases this reduction in office visits is transient, with most providers regaining ability to charge for as much as 80% of their pre-EHR visit volume within six months to a year. Still, 20% long term savings is significant and could probably be optimized further by introducing more speed tempering features into certified EHRs. Equally rigorous studies show preliminary evidence that the savings realized from introducing fully functioning EHRs in Emergency Departments far exceed those in the ambulatory sector. Unlike other Socialist countries that were compelled to nationalize the entire health care system just so they can reduce productivity and discourage utilization by creating long waiting lines, Yankee ingenuity is producing better results at lower costs.

Banishment of THE Pen – The Physician Pen has been long known for being the most financially devastating instrument ever invented. In spite of pharmaceutical reps efforts to the contrary, EHRs are successfully removing all pens from medical practice, including but not limited to, the Physician Pen. Where physicians used to carry several handsome pens in that little pocket right under their embroidered name and title, they now carry an EHR contained in a device that may or may not fit in a less accessible pocket and either way requires both hands, ample light and an adequate supply of battery power to order the simplest thing. The better EHRs also provide various speed bumps on the road to ordering by popping up multiple warnings and good financial advice equidistantly placed at 10 to 15 milliseconds intervals. Data from the very similar retail industry shows that impulse buying is greatly increased by simplifying the process, such as the one-click checkout at Amazon. The reverse logic must also be true, so increasing complexity should reduce impulse ordering in medicine. Judging by Amazon’s successful strategy, the savings in health care are expected to be spectacular.

Customer Intimidation – As EHRs become better at measuring the abysmal state of our health care non-system, and expose the horrors and frequency of medical errors by either careless omission or profit-driven commission, it is estimated that health conscious consumers will increasingly avoid dangerous encounters with the medical complex, thus further reducing utilization and cutting costs. Strategic publicity campaigns advertising security and privacy breaches in other computerized industries, and in health care if any are found, should eliminate another segment of customers. However, the largest cost savings are projected to come from customers refraining from seeking care for, or even mentioning, potentially embarrassing health problems for fear of public exposure through interconnected EHRs.

Accelerated Attrition – EHRs are very powerful tools. So powerful that the prospect of having to purchase and use an EHR is more than enough to prompt older physicians, particularly those in private practice, to consider retirement or transition to other occupations. The evidence shows that there is direct anecdotal correlation between negative reaction to introduction of EHRs and acceptance of cost-saving team approaches to provision of medical care. The semi-natural attrition of experienced and highly compensated physicians who insist on treating, and charging for, every sore throat and every knee scrape, in spite of mounting evidence that lower paid resources can refer those to appropriate specialists with equal outcomes, should in the course of time increase the amount of savings directly attributable to the prevalence of EHRs.

Free Labor Procurement – EHRs are particularly adept at encouraging and showcasing the historical selflessness and ethical conduct of medical doctors, by providing multiple means for doctors to contribute to the well-being of their patients practically free of charge, at all hours of day and night. From the ubiquitous email to the occasional webcam session to the continuous evaluation of uploaded self-quantification vital data from patients empowered to have their health expertly monitored, physicians using EHRs can provide this simple courtesy service to their customers from the office, the home, the yacht or the golf course. These proactive preventative measures should result in extensive reductions in disease burden. Constantly connected physicians, armed with the latest monitoring tools, could detect strokes, heart attacks and maybe even cancer years before actual manifestation of symptoms. And at no cost to society.

The implications for policy makers are pretty straightforward. EHR adoption should continue to be encouraged at all costs. EHRs must evolve to seamlessly and continuously connect to all consumer monitoring devices, which implies a preference for cloud based technologies, and a security breach here and there is not necessarily an impediment to success. EHRs should continue to increase the levels of automated decision support, improve analytics and increase frequency and scope of various alerts. Basically, keep up the good work. We’re right on target.

He killed the audio CD, but resurrected the music industry.

Forever changed the way we look at pictures and videos of your summer vacation or watch summer blockbusters.

Turned your hand-held into a portal to the World Wide Web.

Historians will long debate the role Steve Jobs and his company played shifting paradigms in all sectors of our economy – from media to manufacturing to the practice of medicine.

Really? The practice of medicine?

Has Jobs and his company really changed the art of practicing medicine as they have changed most other corners of our lives?

And if so, how significantly? As much as – say Vesalius, Hooke, Hood or other giants in the field?

A radical supposition perhaps. But there is no denying the impact of the technologies adopted as a result of his touch.

Medical practitioners these days use mobile/connected devices to learn, stream, take continuing medical education, monitor patients in real time, prescribe, ensure compliance, download and consume digital media, and perhaps most importantly, collaborate and communicate more robustly.

Why?  Well, largely, because there’s an app for that.

Heightening the level and rate of electronic exchange does not necessarily mean change for the better in regards to patient care. It is still unclear whether individual patients will enjoy improved diagnosis and treatment as the gradual shift in medical practitioner from clinician to technician evolves (or devolves, as some believe).

Better patient care is what it is all about… isn’t it?

That we are all wirelessly wired in more unforeseen ways everyday is not all due to Jobs and his company. Not by a long shot. And thousands of companies big and small are breaking new ground in the delivery of healthcare everyday. Apparently, healthcare is a thriving, growing market!

One example – More patient questions are asked and answered on Google everyday than by all the healthcare workers in the world, according to Roni Zeiger, MD – chief health strategist for Google.

Another – patient communities and crowd sourcing solutions to medical conundrums have being embraced by mainstream researchers and institutions.

And I am sure those of you who visit doctors have noticed prescriptions never touching your hands, and doctors talking into their tablets or laptops as they conduct your annual physical.

Medical practice is changing.

Which brings me back to Apple and its founder’s drive for a seamless user experience.

Jobs’ abilities, his unique vision, decision making ability, consumer usability perspective, sense of design, strength of conviction, ability to assemble a great staff, and relentlessness propelled him and his firm – coincidentally or intentionally bearing the same name as the forbidden fruit and as well as Beatle’s record label – to an exalted folkloresque place in corporate America. He wouldn’t be admired if his products didn’t deliver on their aspirational promises.

By the way, I think I forgot communicate in that list above. Jobs had a unique ability to communicate his vision as well.

I say this not personally owning any Apple products. I am not now and have never been a fan-boy of either Jobs or his company.

I admire beautiful design and best in class features and functionality. If I get most of the same for half the price – that is generally the way I go. You are not likely to find me sitting outside on the sidewalk waiting for the latest release at midnight.

But these are my biases.  Clearly there are enough Apple-ites to spur entire Apple store knock-offs in China, and propel the company to #1 on the Market Capitalization Charts – briefly unseating Exxon as the world’s most valued company – worth more than the top 32 banks in the EuroZone!

Not bad for a business started in a garage. For a guy fired from his own start-up.

I do not know whether Jobs will be seen as a healthcare revolutionary.

But I do wish for him – that new collaborative techniques enabled by technology his company helps mainstream will sustain his energy and creativity as he transitions to the next phase of his life.

During the healthcare reform debate, I wrote that most people’s attitudes to it were “confused, conflicted, clueless and cranky.”  A major reason was that the American healthcare “system” is fiendishly complicated and few people really understand it.   As a result hardly anyone knows much about what is actually in the reform bill (but that does not prevent them from having strong opinions about it).  Sadly, the reforms, whatever their merits, will make the system even more complicated, the administration more Byzantine and the regulatory burden more onerous. System complexity.

The American healthcare system is already by far the most complex and bureaucratic in the world.  We were once asked to spend ninety minutes explaining American healthcare to a group of foreign health care executives.  Ninety minutes?  We probably needed a few weeks.  Most other countries have relatively simple systems, whether insurance coverage is provided by a government plan or by private insurance or some combination of these.  But in the United States insurance coverage, for those who have it, may be provided by Medicare Parts A, B, C, and D, 50 different state Medicaid programs (or MediCal in California), Medicare Advantage, Medigap plans, the Children’s Health Insurance Plan, the Women, Infants and Children Program, the Veterans Administration, the Federal Employees Health Benefits Program, the military, the hundreds of thousands of employer-provided plans and their insurance companies, or by the individual insurance market.  This insurance may be paid for by the federal or state governments, by employers, labor unions or individuals.  Some employers’ plans cover retirees, others do not. The result is that the system is pluralistic, mysterious, capricious and impossible for most patients and providers to understand.

Administrative complexity

The administrative complexity is amplified by the multiplicity of insurance plans.  About half of all Americans with private health insurance are covered by self-insured plans, each with its own plan design.  Employers customize their plan documents, led by consultants who make a good living designing their plans and tailoring their contracts. As one prominent consultant told me recently, if all the self-insured plan documents were piled on a table they would not just exceed the 2,700 pages of Obamacare, they would probably reach the moon.  For the rest of the commercially insured population, health plans may be traditional indemnity plans, Preferred Provider Organizations or Health Maintenance Organizations.

The coverage provided by different plans varies dramatically.  They may or may not include large or small deductibles, co-pays or co-insurance.  Beneficiaries may pay a large, small or no part of their health insurance premiums.  Some plans cover dependent family members and children, others do not.  The Medicare Part D pharmaceutical benefit plan involves a “doughnut hole,” which will disappear as health reforms are implemented.  Surveys have found that few people fully understand their own insurance plans let alone the bigger picture.  While health reform takes some steps toward standardization of insurance offerings and improving transparency, overall it is likely to increase complexity.

Physicians may be paid by salary, fee-for-service, or capitation, with “pay for performance” bonuses based on complicated metrics.  In order to get paid, most doctors and hospitals have to use many thousands of codes to describe the care they have delivered.  Doctors can spend hours a day doing this; hospitals employ tens of thousands of coders; insurance companies and government programs spend a small fortune entering and checking this coding.  A substantial proportion of payment claims are disputed, further increasing administrative costs and the “hassle factor.”

Some insurance companies are for-profit, some are not-for-profit.  Hospitals may be for-profit, not-for-profit charities or be run by federal government agencies such as the VA or the DOD or by cities.

The administrative complexity exists in the private and public sectors and in both for-profit and non-profit organizations.  Medicare is relatively efficient because it has a simple criterion for eligibility – your age (although it also covers people with disabilities).   But for many of us administrative complexity is rampant because health insurance is a function of our jobs or our income (or lack of it). Our insurance changes often (because our employers change their plans, because we change jobs or because our income changes), far more often than it does in other countries.  As a result we have armies of people who sell insurance, keep track of who is eligible for what, chase, authorize or deny payments, and lob faxes, emails and assorted missives at us and each other. In Los Angeles County, 1,900 people work on nothing but MediCal  eligibility with a union-mandated productivity target of completing two forms a day.   There are an estimated 150,000 such eligibility workers across the country.  The health reform bill proposes to expand Medicaid by 16 million so the number and cost of these workers will surely increase.

Regulatory complexity

Different parts of the healthcare system are managed or regulated by dozens of Federal government and state agencies, including the Department of Health and Human Services, the Center for Medicare and Medicaid Services, the Centers for Disease Control, the Veterans Administration, the Food and Drug Administration, and the Agency for Healthcare Research and Quality.  One report claims that the health care reform bill will create 183 new agencies, including state insurance exchanges and a Medicare Independent Payment Advisory Board (IPAB) and the Center for Medicare and Medicaid Innovation.

And then there are the acronyms.  If you don’t know them you will not understand much of the health policy debate: PPACA, DHSS, FDA, CMS, VA, CDC, AHRQ, SRG, MLR, HMO, PPO, PBM, COBRA, P4P, CER, EMR, HIT, DRG, FEHBP, WIC, CHIP, DSH, MMA, and many more.

I believe that this complexity is a major reason why we have (and this is very well documented) the most expensive, inequitable, inefficient and unpopular healthcare system of any developed country, with poor to mediocre outcomes.  The problem is not the doctors or the hospitals, but the system. Reimbursement, with its many thousands of points of public and private sector payment and the mindboggling payment rules, creates a bow wave of administrative costs and many perverse incentives.  And these costs are the incomes of powerful interests who fight to preserve them.

The American “system” is exponentially more complicated than the systems in other countries – and the reforms will make it even more complicated.  Unfortunately reform that would simplify the system is probably not politically feasible.  A benign dictator might scrap the system and start over with a much simpler system.   But in a democracy, with powerful interests and 17% of our economy involved, “you can’t get there from here.” We have to build on what we have, heaping complexity on complexity.

It is therefore no wonder that surveys find most people (including, it would appear, many members of Congress) understand very little about the health care system let alone health care reform.  A recent Harris poll asked people which of 18 items are or are not in the reform bill.  Modest majorities  were able to give the right answer for only 4 of the items.   And pluralities got the answer wrong on nine of the items.  For example pluralities believed that the bill includes higher income taxes for the middle class, new ways to ration care, a new government run health plan, cuts in Medicare benefits, increased payroll taxes and “death panels”.

I’m often asked why healthcare has been slow to automate its processes compared to other industries such as the airlines, shipping/logistics, or the financial services industry.

Many clinicians say that healthcare is different.

I’m going to be a bit controversial in this post and agree that healthcare has unique challenges that make it more difficult to automate than other industries.

Here’s an inventory of the issues

1.  Flow of funds – Hospitals and professionals are seldom paid by their customer. Payment usually comes from an intermediary such as the government or insurance payer. Thus, healthcare IT resources are focused on back office systems that facilitate communications between providers and payers rather than innovative retail workflows such as those found at the Apple Store.

2. Hiring and training the workforce – Important members of the workforce, the physicians delivering care, are seldom employed by the hospital. This is rare if not non-existent in any other industry. It’s as if Toyota built a factory that anyone can use but does not hire or train the workers who build cars. If someone wanted to create a Toyota with wings and an outboard motor, they would have the freedom to do it.

3. Negotiating Price – Reimbursement no longer is based on a price schedule hospitals and professionals can control. It is based on a prospective payment model such as DRGs that someone else designs and dictates. Where else in the US do prices get dictated to a firm?

4. Establishing referral relationships – We cannot market services to those who control our patient flow due to Stark anti-kickback regulations. In other industries, you can build relationships, offer special incentives, and arrange mutually beneficial deals to develop your referral business. In healthcare, it’s illegal even when unilaterally funding an action would make things easier for both parties and the patient.

5. Standardizing the product – In most industries, the product or service can be standardized to improve efficiency and quality. In healthcare, every person is chemically, structurally, and emotionally unique.   What works for one person may or may not work for another. In this environment, it is difficult to standardize and personalize care in parallel.

6. Choosing the customer – In most other industries, you can choose with whom you do business. Not so in healthcare. If you have an emergency department, you must provide treatment even if the customer has no means to pay.

7. Compliance – Data flows in healthcare in increasingly regulated. What other business, including the IRS, is required to produce, on-demand, a three year look back of everyone who accessed your information within their firm.

As I noted in speech about the Burden of Compliance “the more complex a health system becomes, the more difficult it becomes to find any system design that has a higher fitness.”

We are successfully automating healthcare workflows, motivated by HITECH incentives and the requirements of healthcare reform. The seven characteristics above have required vendors to create full featured software applications and organizations to create complex rollout/funding models that take time. By 2015 we will be there and I will be proud of all we’ve accomplished, given that the constraints on the healthcare industry are truly different than industries which have been earlier adopters of technology.

According to Kevin Pho, MD, if you’re a physician or hospital that relies on Medicare payments, grim times are ahead. I agree, as I believe it will be even worse than the scheduled 29% payment cut that’s scheduled to go into effect in 2013. Bottom line – It’s a terrible deal for health care providers.

Under the contentious debt ceiling agreement, significant cuts in Medicare dollars will be made. But beneficiaries are mostly protected. Instead, it’s the physicians and hospitals who will be affected the most.

According to Politico,

“Under terms of the hurried deal, the 12-member joint committee would be charged with crafting proposals that trim at least $1.2 trillion in federal spending over the next decade. Those savings could be found in a number of programs, including Medicare and especially Medicaid, which the White House has signaled it would be open to.”

If the panel can’t come up with enough savings, automatic cuts would go into effect. Medicaid, Social Security and veterans’ benefits would be protected. But providers could see a 2 percent cut in Medicare reimbursement.”

Worse, if the Congressional super committee cannot come to an agreement, a “trigger” will automatically make draconian Medicare cuts. And, yes, those cuts will specifically target provider payments.

The trigger is meant to be unappealing to both political parties, in order to incentivize them to come to a deal. For conservatives, that means deep cuts in military spending.

But for Democrats, the cut in Medicare primarily targets providers and hospitals, and leaves beneficiaries mostly untouched. That doesn’t seem too unappealing for progressives, as most believe physicians are overpaid anyways. That’s why some are saying Democrats may even prefer the trigger to a deal.

Furthermore, Politico also notes that the decision whether to “trigger” deep provider Medicare payments come at the same time as extending the doc fix.

To put it in plain terms, I wouldn’t be surprised to see deep cuts in provider and hospital Medicare payments, on top of the previously scheduled 29% cut sans doc fix. We’re talking a combined 30-40% cut or more. So, if Medicare patients are having a hard time finding a doctor now, it’s nothing compared to the shortages that will come soon.

Recently, Michael Zhuang wrote that the physician lobby was suspiciously quiet during the debt ceiling debate:

“Compared to lawyers, the insurance industry, and even seniors, time and time again physicians have failed to make their voices heard. No wonder their interests get sacrificed in every political turn of events.”

Now that we know the outcome, and the horrific impact on Medicare providers, it’s clear that we’ve paid a steep price for our silence.

The many challenges in healthcare today require great leadership. Access, affordability and quality are just a few of the overarching issues that call for and, in fact, demand great leadership from within healthcare.

Traditionally, the criteria for a physician to advance to a leadership position have included academic and/or clinical accomplishments, rather than the distinctive competencies needed to lead. Furthermore, traditional physician training and the unique characteristics of physicians — we tend to value autonomy and, outside of structured interactions (such as the operating room or intensive care unit), may have poorly developed team reflexes — can handicap developing leadership skills.

Though developing great leaders and embracing change are well-established characteristics of frontrunner organizations in many industry sectors, healthcare organizations have generally lagged behind. What’s more, many healthcare organizations are structured in silos or “fiefdoms,” which represent a challenging environment in which to lead. Only recently are healthcare organizations awakening to the importance of developing physician-leaders and, in this context, offering physician-leadership programs.

I suggest that four features of physicians and medical training may conspire against physicians’ having instincts or “reflexes” to collaborate. I believe that physicians:

1. experience long and hierarchical training, often with extended subordination;

2. are extensively evaluated, usually based on individual performance (e.g., board certifications, competition for training slots, etc.) rather than on group or team-based performance (which many suggest is more relevant to achieving excellent clinical outcomes);

3. may experience “extrapolated authority,” in which we extend the clinical authority that is conferred to us by patients (i.e., to address their illness and contribute to their well-being) to settings for which this clinical authority is irrelevant (e.g., driving on the highway, getting on an elevator, etc.); and

4. are “deficit-based thinkers;” specifically, because differential diagnostic thinking encourages physicians to identify problems (deficits) and because clinical skill reinforces the value of problem-solving, physicians may be hampered in the ability to adopt an “appreciative” type of thinking that is felt better suited to solving organizational challenges.

As an example of appreciative thinking, appreciative inquiry is an approach to organizational change and opportunity that builds momentum for change based on images of “the best of what could be” rather than the shortcomings of the current state. Because of the strong reflex for deficit-based thinking, physician-leaders must learn to switch nimbly between different reasoning and thinking processes — one that is “deficit-based,” narrowly focused and well-adapted for clinical practice and another that is more divergent or “appreciative” for thinking about organizational or system issues and challenges.

As another example of the skills needed to lead, in a study published in the American Journal of Medicine in 2006, interviews of 10 academic internal medicine chairs were conducted to determine the competencies for organizational success. The chairs identified several critical leadership success factors including mastery of visioning, communication, change management, “emotional intelligence” (EI), team building, business skills, personnel management and systems thinking. Emphasizing the importance of EI, which consists of competencies regarding self-awareness, self-management, social awareness and relationship management, these chairs “stated that this ability was fundamental to their success and its absence the cause of their failures.”

When physician leaders are selected based on traditional academic and clinical success rather than on leadership readiness or skill, we can identify both a gap and an opportunity. As one chair stated, “The fact is that the majority of chairs are chosen for skill sets that have little to do with the skill sets they are going to need to use.” In this gap between current practice and actual need lies the rationale and energy to develop physician-leaders.

The healing mission and ethical imperative of medicine further underscores the importance of optimizing physician-leaders’ skills. Congruence with a healing mission requires that physician-leaders possess and model the traits of compassion and hopefulness, traits that inform “resonant leadership.”

Finally, there is a clamor for leadership development among current trainees, who identify important deficits and needs for leadership training. For example, in a survey of surgical residents at a large academic medical center, more than 75 percent identified a deficit in their knowledge of leadership theory and in specific traits (e.g., conflict resolution); more than half reported at most average competence in other traits (e.g., challenging the status quo, inspiring others, helping others optimize performance, etc.).

At the same time, questions that require further attention include: (1) What are the competencies that characterize the optimal physician-leader and (2) what are the features (e.g., format, curriculum) of the ideal program to train physician-leaders?

After much research and observation, I have suggested six domains of needed competencies for effective physician-leadership. These competencies include: (1) technical knowledge (e.g., operations, finance and accounting, information technology and systems, human resources (including diversity), strategic planning, legal issues in healthcare and public policy); (2) knowledge of healthcare (e.g., reimbursement strategies, legislation and regulation, quality assessment and management); (3) problem-solving prowess (i.e., around organizational strategy and project management); (4) emotional intelligence (i.e., the ability to evaluate self and others and to manage oneself in the context of a group); (5) communication (i.e., in leading change in groups and in individual encounters, such as in negotiation and conflict resolution); and (6) a commitment to lifelong learning.

Although many questions remain unanswered, such as what are the best learning formats in which to cultivate these competencies and at what point in one’s training are the competencies best developed, I believe that those institutions that discover the answers and implement the solutions will design the future of leading healthcare.

The past year has seen a huge jump in the number of hours that physicians spend  online; at the margin, the increase  is due to physicians’ use of online via mobile platforms.

Meredith Abreu-Ressi, President of Manhattan Research, shared her insights into the firm’s study, Taking the Pulse (v. 11), with me today. The top-line finding of the annual survey is that health  professionals have quickly adopted mobile platforms in health — with special attention paid to Apple products, the iPhone and the iPad.

Manhattan Research has tracked physicians’ use of online health resources for over a
decade. They’ve found “plateaus” and “jumps” over the years, largely related to changes in bandwidth. In the early days of doctors’ use of online health sites; they spent two to  three hours a week seeking information online. As faster speeds became available to physician offices, such as T1 lines, those hours increased to five, then to 8 as more doctors accessed the Internet via cable and DSL.

This year, the survey found that  30% of doctors have an iPad. In the firm’s 2010 survey, the device hadn’t even been released. This is tremendous adoption in the first year of any device, particularly among the user group of physicians.

What was new this year in Taking the Pulse is that Manhattan Research conducted some in-depth, qualitative interviews with physicians. Ressi said that the power of the iPad’s  3G network combined with portability drove doctors using the Apple tablet to "love” the platform — as well as for iPhones, which have replaced Blackberry as  physician favorites for mobile phones.

Ressi expects the iPad will be a  beloved platform for EMR adoption. In qualitative
interviews, the survey found that physicians accessing EMRs through tablets had much more positive comments about the “EMR experience” than physicians using EMRs on desktop computers. There is a lot of interest among all physicians to access EMRs via  tablets.

What’s compelling for those  physicians who use iPad-based EMRs is their ability to
access the record anytime, anywhere, portably. Doctors can move from exam room to consultation room to another exam room, having all of the information essentially “with” them. They can easily take the device home and get work done in a seamless way  grabbing minutes available between family time. For example, Ressi told me of a doctor interviewed who said he sat in the car while his family went into the  grocery store so he could take those few ”interstitial” minutes to catch up with email, check on a patient’s lab results, and email that patient their results with a few lines of context. This highlights the
busy life of physicians — and  how a portable, user-beloved device like the iPad can enhance professional productivity, even a few minutes a day. “The tablet is a little thing that makes  it easier to stay connected and do their job better,” Ressi inferred.

For physicians not using the iPad  or another tablet to access an EMR, “they aren’t
getting glowing endorsements,” Ressi reported. A representative comment one physician told Manhattan Research in the qualitative interview was, “It turns us into secretaries.”

Taking the Pulse also found that 7% of physicians  are using some form of video to consult with patients. “Video” is used quite  broadly here, from telemedicine and telehealth to online consultations with patients and fellow physicians via Skype. One
psychiatrist interviewed uses video to provide medical care to people incarcerated in  prison.

Key Points: The dramatic growth of tablets, and especially iPads, among physicians tells an important story about design, usability, and productivity. Physicians have quickly cottoned onto this particular mobile device because those who use find it increases professional productivity because it’s portable, intuitive to learn, and fast. Furthermore, tablet-using physicians say they like how it enhances patient-physician communication.

Doctors tethered to a paper chart or desktop computer can’t easily break their eyes away to visually engage with a patient during an exam. Something about the iPad, physicians find, opens up communication with patients. This can bolster greater trust and health literacy, opening up communication channels between patient and provider. This is a  prerequisite for connected health. It’s not about the device itself — which is  indeed beloved among its adopters. It’s what that device can do for physicians in their daily lives and workflow that drives its beloved brand status.

I’m amazed at just how quickly physician employment has swung from small independent practices to hospital-based employment. I’ve heard about it anecdotally from medical societies and malpractice carriers who are seeing their constituents shift, and have certainly observed the shift from individual physicians, but I’m still surprised how fast it’s occurring. A new report from recruiter Merritt Hawkins tells the clearest story I’ve seen:

> In  the last 12 months, 56% of physician search assignments have been for hospital  jobs, whereas 5 years ago it was just 23%

> Just 2% of assignments were for independent, solo practice doctors compared with 17% 5 years ago

Doctors are becoming more like regular wage earners, albeit high paid ones. There are
some strong drivers of this trend including the need to support health information technology, comply with regulations and deal with health plans. There’s also a desire on the part of a younger, increasingly female physician workforce to have a better balance  between work and home life. If anything the forces pulling physicians into hospital employment will strengthen in the near term with the arrival of Accountable Care Organizations and other forms of deep integration.

Yet when a pendulum swings it tends to swing too far. Especially considering how
quickly things have moved, I do expect that there will be some backlash to the rush into employment. It’s really not all that much fun having a boss, especially when that boss is a big, bureaucratic hospital with other things on its priority list besides MD satisfaction and career development. Patients may not like it so much either. I know I’d rather see a physician who’s not too tightly tied to a  hospital.

So what will the reversal look like? I don’t think it’s going to be doctors rushing to put up their own shingles or buy practices of retiring doctors like in the old days. Instead I expect to see a new breed of physician employers who recognize what’s needed to make doctors happy, treat patients well, manage compliance, and still make money. One example is so-called direct primary care practices such as Qliance. Time  will tell what other forms develop.

Doctors practicing in the U.S. are becoming increasingly conscious of the increasing costs of health care. Most consider themselves cost-conscious, and are considering the impact of their practice patterns — in terms of prescribing medicines, tests, and procedures — on the nation’s health bill. In fact, most physicians feel they have a responsibility to bring down health costs.

This perspective on physicians comes from the survey report, ‘The New Cost-Conscious Doctor: Changing America’s Healthcare Landscape,’ from Bain & Company, published in March 2011. Bain spoke with over 300 U.S. physicians to assess their perspectives on managing costs, drug and device usage, and standardized care protocols.

The top-line finding is that, regardless of physician demographic — whether male or female, salaried or productivity-based, specialist or generalized, urban or rural, young or mature, doctors uniformly see that they must change clinical practice patterns to accommodate the realities of health economics.

The impacts of this on the practice will be many, including:

• Consolidating practices, increasingly being absorbed into hospital systems
• Decreasing utilization as a direct response to incentives
• Promoting preventive care
• Adapting to standardized treatment protocols.

Key Point to Ponder:

Bain rightly points out that these changed physician attitudes and behaviors will ripple through the health supply chain on to life science, medical device, pharmaceutical and technology companies. Organizations in these health supply segments must demonstrate value to physicians and patients in the larger health ecosystem in order to be adopted into clinical practice.

That physicians see cost management as part of their jobs now means that their decisions will be increasingly impacted by their collective cost consciousness lens. Accountable care models, medical homes and more tightly integrated delivery networks will bolster this approach and tightly focus that cost conscious lens. Physicians will be less inclined to try out new-new products without firm proof-of-concept and references from peer physicians who are influencers in their field. Over one-half of physicians told Bain that they’d be using comparative effectiveness analyses within two years.

Furthermore, physicians are growing more comfortable with practice protocols and standardized care, Bain found. They’re using clinical guidelines more often in 2011 than five years ago; this is especially true of younger physicians, who more often refer to practice guidelines for patients. The mass adoption and full implementation of electronic health records will enable such protocols to be pushed to clinicians at the point-of-care. In fact, physicians expect a five-fold increase in the prevalence of electronic access to clinical treatment guidelines, and an eight-fold increase in pay-for-performance programs.

For manufacturers in the health supply chain, the major challenge is to develop and market products that help lower the costs of health care. That’s the new definition of “innovation” in healthcare.

The following is an article written and reprinted in its entirety by Senator Bernie Sanders (Independent) from Vermont that mirrors my beliefs when it comes to health care reform and the only possible solution.

The United States is the only major nation in the industrialized world that does not guarantee health care as a right to its people. Meanwhile, we spend about twice as much per capita on health care and, in a wide number of instances, our outcomes are not as good as others that spend far less.

It is time that we bring about a fundamental transformation of the American health-care system. It is time for us to end private, for-profit participation in delivering basic coverage. It is time for the United States to provide a Medicare-for-all, single payer health coverage program.

Under our dysfunctional system, 45,000 Americans a year die because they delay seeking care they cannot afford. We spent 17.6% of our GDP on health care in 2009, which is projected to go up to 20% by 2020, yet we still rank 26th among major, developed nations on life expectancy and 31st on infant mortality. We must demand a better model of health coverage that emphasizes preventive and primary care for every single person without regard for their ability to pay.

It is certainly a step forward that the new health reform law is projected to cover 32 million additional Americans, out of the more than 50 million uninsured today. Yet projections suggest that roughly 23 million will still be without insurance in 2019, while health-care costs will continue to skyrocket.

Twenty-three million Americans still without health insurance after health reform is implemented? This is unacceptable. And that is why, this week, Representative Jim McDermott and I are announcing the re-introduction of the American Health Security Act, recognizing health care as a human right and providing every US citizen and permanent resident with health-care coverage and services through a state-administered, single payer program.

Let’s face it: until we put patients over profits, our system will not work for ordinary Americans.

It is incomprehensible that drug companies still get away with charging Americans twice as much, or more, than citizens of Canada or Europe for the exact same drugs manufactured by the exact same companies. It is an outrage that insurers still often hike premiums 20%, 40% and 60% a year on individual policy holders; and some insurers still spend 40 cents of every premium dollar on administration and profits while lavishing multimillion-dollar payouts on their CEOs.

It boggles the mind that approximately 30% of every health-care dollar spent in the United States goes to administrative costs, rather than to delivering care. We must do better. Taiwan, for example, spends only a little over 6% of GDP on health care, while achieving better health outcomes on some key indicators than we do; yet they spend a relative pittance on administrative costs.

I am very proud that my home state of Vermont is now taking big steps to lead the nation in health care by moving forward on a plan to establish a single payer health-care system that puts the interests of patients over chasing profits. The American Health Security Act would make sure every state does the same — taking profits out of the equation by implementing a single-payer system, but letting each state administer its own program, according to strict standards, in a way best suited to its needs.

The goal of real health-care reform must be high-quality, universal coverage in a cost-effective way. We must ensure, to as great a degree as possible, that the money we put into health coverage goes to the delivery of health care, not to paper-pushing, astronomical profits and lining CEOs’ pockets.

Bernie Sanders is the U.S. Senator (I) from Vermont, and the longest serving independent member of Congress in American history. He is a member of the Senate’s Budget, Veterans, Environment, Energy, and H.E.L.P. (Health, Education, Labor, and Pensions) committees.