Checklists?
Atul Gawande's latest book, The Checklist Manifesto, advocates checklists to systemize the complexity of healthcare delivery and reduce medical mistakes. Making the media rounds, Gawande spoke for an hour recently on Democracy Now. He also testified before the President's Council on Science and Technology (PCAST).
Checklists, you ask? Certainly they're not new. Indeed, a few years ago, another physician, Dr. Peter Pronovost presented research showing the utility of checklists to tackle infectious disease in hospitals, and of course they've been used by airlines, oil change places, pizza delivery people, families going shopping, etc. Gawande's rendition appeared in this piece for The New Yorker in 2007. But his book is especially timely, given the current focus on healthcare reform.
The amount of information in medicine is vast -- 68,000 different patient diagnoses, 4,000 different surgeries, thousands of medicines. But despite our knowledge and exorbitant spending, healthcare outcomes in the US are lower than other industrialized countries -- 37th lowest, in fact, and sinking.
The fee for service incentives derail efficient healthcare, for instance by encouraging surgery. There are 230 million surgeries a year, 50 million in the US. Problematically, more surgeries means more surgical complications. The number of surgeries outstrips childbirths in the US, according to Gawande, but with 10-100 times the death rate. As he puts it, "150,000 people who die of complications of surgery, die within thirty days following surgery. And we know at least half are avoidable."
Gawande et al conclude that checklists help reduce mortality and morbidity from surgery and infections. Gawande also says they increase teamwork during procedures, for instance, by empowering nurses to point out missed checklist items. Better teamwork in turn increases success rates.
Checklists are not the complete solution to avoiding deaths, but when Gawande conducted research using checklists in eight hospital centers and 7,688 patients across the globe, the researchers found that deaths decreased by 46%, which, as a percentage looks quite dramatic, but according to their research surgical teams reduced deaths from surgery from 1.5% before the checklist to .8% afterwards. Serious complications fell from 11% to 7% according to the study, published in the New England Journal of Medicine (NEJM) last year.
Checklists as Partial Solution
But if the improvements observed by the research teams aren't artifacts, checklist implementation is still not without other issues. Harold Varmus pointed out in the PCAST panel that checklists could impede creative solutions, and noted that investigations into best practices inevitably unveil multiple equally effective ways of solving medical challenges.
As well, according to Gawande, sometimes checklists impede profit. There are strong financial incentives encouraging doctors to do procedures like surgeries. Gawande wrote last summer about the high cost of healthcare in McAllen Texas, where Medicare spends $15,000 per enrollee because entrepreneurial doctors have found ways to profit mightily within the fee for service system. In Boston, although the checklists reduced emergency asthma admissions at Boston Children's Hospital by 80%, asthma admissions were the number one revenue source for the hospital admissions. The surgeon stressed that payment systems need to be adjusted when necessary, checklists won't work on their own. The problem of keeping costs down he told Democracy Now, has not been accomplished by insurance companies.
Checklists: Simple and Cheap, Dumped into a Technology Centric World?
One of Gawande's chief points is that checklists are simple and cheap to implement compared to proposed solutions for healthcare which involve ever more complicated technology that doesn't necessarily scale. As Gawande says: "There are technologies that we've tried to introduce. We've pursued very expensive solutions. But what we've not recognized is that we can pursue an idea like checklists...".
When Gawande presented these views to the President's panel, he ran into some interesting opinions from some in the IT sector who sit on the panel. His low tech solution elicited questions like: "Will physicians accept technology?"
Gawande observed that there "can be a sense of seeing the technology almost as a panacea". Problematically he says, although technology can be beneficial, "we have not really gathered evidence on what the components are that make it a successful implementation versus unsuccessful". Two systems in two different organizations can save lives and money in one institution and be a total failure in another, as was the case with a physicians' order entry system that Brigham Women's successfully implemented, which then failed to deliver cost savings and life saving benefits when implemented at Cedar's Sinai.
No sooner had he said this, when Eric Schmidt, Google's CEO who sits on PCAST, asked him why doctors didn't use technology more. Schmidt tried to get some insight for "the model of healthcare that we'll have five or ten years from now."
"It's pretty clear that we'll have personal health records and you'll have the equivalent of a USB stick or cloud based medical history. You'll show up at the doctor with some set of symptoms. And in my ideal world what would happen is that the doctoor would type the set of symptoms that they see as a doctor and they would be matched against this data that is a repository. And then a knowledge engine would use best practices and all the knowledge of the world to then give the physician some standardized guidance. This is a generalized form of your checklist mechanism. As a computer scientist, this is a platform database problem...And it's also knowledge engineering problem.
We do these very, very well, as a general rule in computer science. And it befuddles me why medicine has not organized itself around this platform opportunity. Do you have an opinion as to why not? Do you have an opinion as to how such a system would evolve so that the doctors would use it, it would standardize practices in the way you described and ultimately lead to presumably debates over healthcare and what the right outcomes are and all the kinds of incentives. If you don't have such a platform you'll never measure it to scale...
There are a lot of assumptions implicit in Schmidt's statements, we won't go through them all here, although some physician/commentators on the internet have already had a field day. Gawande started out responding that the people who make those systems "don't know how the clinical encounter works" -- six problems in 15 minutes per patient, for starters. He ended up more conciliatory towards the idea of computerized checklists. But he emphasized that his checklists involve understanding systems engineering issues involved with ensuring well-functioning teams. That checklists were not simply a challenge of listing as Schmidt put it "all the knowledge in the world".
Gawande also proposed to the President's Council of Advisors on Science and Technology a new "science of health delivery" to study systems innovations, team organization and motivations, and coordinated deployment of healthcare. He even suggested a "National Institutes for Health Systems Innovation" to stand apart from the NIH (although such new agencies are fun to dream up but practically improbable).
Moving Forward on Platforms
For all the issues brought to the fore in "Checklist Manifesto", and for the all the issues at stake in healthcare, and to Gawande's warning about technology panacea's, it was interesting that the panel ended up quickly focusing on healthcare records. It's easy to imagine the temptation to look to health care records as that very panacea. A lot of the failures in medicine are also failures of communication, between the patient and doctor (15 minutes is often generous), between doctors, between facilities. Certainly technology already helps a lot of this, but for all the improvements in medical information technology to date, medical care is still fragmented, expensive, fraught with inconsistency and at times dangerous to the patient. Still, technology is necessarily part of the solution, and building the platform is critical.
So how would a new healthcare IT platform change the current medical system? There's a lot at stake for doctors and for patients. Any major change to the system could rearrange profits. Much of the routine patient care could be accomplished via a computer and a nurse or administrator. Why does a doctor need to charge $200 to tell you to take aspirin and drink fluids? Both Google and Microsoft are positioning themselves well -- it's hard to imagine either not grabbing the opportunity to root itself themselves into healthcare, they have a lot of mouths to feed back on their campuses.
It's troubling that the primary recipient, the patient, isn't very well represented in any of these discussions except by proxy of Google and various university doctors. 'We know what's good for you and we'll tell you what that is.' Everyone is advocating for "the patient", but Google is advocating for itself as well, as is Microsoft. And do university doctors in the upper echelons really experience the same problems with healthcare that your average patient does? That's what you get with 3rd party healthcare payers? The primary customer perhaps is not patients but insurance companies, who will no doubt benefit from the knowledge in more comprehensive databases of patient information.
The challenge perhaps is to improve healthcare (behind the patient's back), to not make it worse (no small feat), and to avoid simply adding another layer of expense and bureaucracy, to the gigantic Dagwood sandwich that is modern healthcare. It would be too easy to add more layers, to the layers and layers that comprise healthcare services, insurance, and companies that administer benefits, each one yielding profits from their slice, who in the end complicate healthcare and add costs for ambiguous ends.
