Starting With Curious

Two years ago, I was having trouble finding time to get over to employee health for my flu shot.  One day I went to Walgreens for something, and realized I could get it right then and there, so I did.  I admit, I felt a little tainted, like I was aiding and abetting the enemy.  But it was quick, cheap, and convenient – hard to argue with that for a simple flu shot.

A recent article in JAMA talks about the “convenience revolution,” the innovative options for treatment of low-acuity conditions, including store kiosks and retail clinics, employer-based clinics, “clinic in a car,” and e-visits.  These are examples of the kinds of “disruptive innovations” than Clayton Christensen talked about in “The Innovator’s Prescription.”  It’s easy to be dismissive of these as a “doc-in-the-box,” but we need to be mindful of why they have been growing.  For many conditions, especially in pediatrics, it’s frankly difficult to demonstrate much of a difference between providers and settings in the quality domain of effectiveness.  Let’s face it, most of the time kids with simple illnesses are going to get better no matter what.  So from a consumer perspective, if effectiveness is the same, then the other domains, especially efficiency (i.e., cost), timeliness, and patient-centeredness (i.e., service) are going to be more important.  There is no difference in how well protected I was against the flu by my Walgreen’s shot than by one administered by MCW Employee Health.  But I didn’t have to make an appointment or walk across campus to get it – I could do it when I happened to need to go to the drug store to buy razor blades anyway.

OK, perhaps a flu shot doesn’t matter.  But even something as simple as a sore throat – will the provider at Target perform a strep test correctly?  (Answer: Probably – it’s really not that hard.)  Will she be able to recognize the rare case of epiglottitis or diphtheria? (Answer: Is that a serious question?)  And what happens if everyone starts going to retail clinics for routine things, and only come to their pediatrician or Children’s for things that are more complex?  Or worse, those “convenience clinics” start dealing with some of the more complex things, where there may be a difference in effectiveness or safety.

The answer to those questions is, we can’t let them.  I don’t mean we lobby for restrictions to prevent it – that probably won’t work.  I mean we have to outcompete them.  We must acknowledge the importance of those other domains – service, cost, timeliness – and provide a similar level of convenience.  What kind of “disruptive innovation” can you think of in your area.

And by the way, last year, employee health came to me.

This week’s post will be short, as I am living out our value of Health, specifically, “I am an active participant in my own health and lead a healthy lifestyle.”  In other words, I’m on vacation, and I mean really on vacation, as in no cell phone and no email.  (I wrote this last week.)  I’ve written previously about the work showing a link between rest and rejuvenation and increased quality, productivity, and satisfaction with work.  As anyone who has tried to schedule a meeting over the summer knows, many people do take vacation.  But are you really gone?  Try it out.

While you’re checking out, check out this item about how giving is the key to getting.  Specifically, organizational psychologist Adam Grant, at the Wharton School of Business, has written a book describing how framing work as altruism can lead to improved productivity and satisfaction as well.  In his view, there are 3 kinds of people: takers (those who always seek advantage), matchers (people who give in expectation of a return in kind), and givers (those who give – especially of their time and attention –  without expectation of immediate gain).  While most people are matchers, givers are overrepresented at both extremes of success – they can be taken advantage of, but they are also among the highest achieving leaders.

We speak of the gift of time.  Try giving it to yourself and to someone else.  It could be the gift that keeps on giving.

In a recent post, I talked about the growing interest among our patients and families – driven by increased cost sharing – in understanding what care is costing them, and the difficulty in answering that question.   A recent study in Pediatrics illustrates the problem.  Residents and attending hospitalists at Children’s Hospital of Philadelphia were surveyed about their knowledge of costs, charges, and payments for a range of common tests and treatments.  The respondents were not confident in their knowledge: only 13% of attending and 3% of residents rated their understanding of hospital finances as at least moderately adequate.  The large majority of both groups expressed a desire for knowing more.

It turns out they need to.  The median percent error was 75% for attending and 80% for residents.  Only 15% of estimates were within 25% of the actual value, and the magnitude of errors were similar for costs, charges, and payments.  However, both groups tended to overestimate costs, while underestimating charges and payments.  Arguably, the latter two are what matter most to patients who will have to pay at least a portion of the bill.  In addition, there appeared to be a certain tendency toward the middle: overestimates were more common for the least expensive items, while the costs and charges for the most expensive items tended to be underestimated.

If our patients and families are becoming more price-sensitive, and are asking more about what services will cost them, we need to prepare providers to deal with that.  Moreover, we know that making clinicians aware of costs can reduce unnecessary “routine testing” and other resource utilization.  This study shows that we have a long way to go in terms of getting accurate information into the hands of providers.  One of the advantages of an electronic health record is the ability to embed that information into the ordering process.  Interestingly, the Pediatrics study was done at an institution using Epic; it’s not clear whether they include any price information to the ordering provider.

Transparency, anyone?