Burdens and Burnout

Everyone is aware of clinical burnout and the burdens in and around our healthcare system. Much has been written as to the multitude of driving forces. A few overarching themes seem to be worth noting. Systems complexity and knowledge overload are under appreciated and they have enormous importance in contributing to the burden and the burnout.

Let's begin with clinical knowledge. Science is forever discovering new conditions, new diseases, new therapies and each adds new diagnostics in labs or imaging, etc. Just think about the impact in cancer, in surgical technology with robots, or in genomics. William Stead explored the knowledge requirements in medicine and how it has grown over the years. In addition, he notes human capacity for managing knowledge in the moment of care. Clearly, the amount of knowledge it takes to build a care plan over the life of a condition takes more knowledge than any one individual can harness. It takes a team, a team of primary care, specialty medicine, pathologists, radiologists, anesthesia, surgical teams, rehab and more.

Yet, the business model we have today is dated from 60 years ago when care was very simple and a simple transaction inside fee for service made sense. There are aspects of care today where this still applies - such as in much of Ophthalmology. But the complexity of care in trauma, in oncology, in ortho joint replacement, cardiac care and so forth no longer fits the business model and the pressures on a health system to manage the knowledge and to correlate it to a business model is going to reduce burden and burnout.

There are many efforts to bring forth solutions, mostly from those who have the purchasing power, that is the insurers and the self insured major corporations with large employee base. Each effort is very well-intended and worthy of care model pilots. However, we have to be aware that the needs of transforming care are not just price management or deployment of an EHR or spotty measures of quality. We need alignment of care models with care teams with business models, with cost knowledge, with outcome knowledge, with supporting IT with dashboards, and on and on. Michael Porter describes this in his work from 2006 in Value-Based Healthcare Delivery in detailing the elements of an integrated practice unit (IPU), consistent with a bundle of care.

When each payer adds their own IPUs or episodes onto a delivery system, that delivery system needs to build out supporting operations to manage the contract and the risk it brings. These are highly complex activities, spread across a lengthy time window - up to 3-6 months - with multiple parties involved. In the enclosed complexity model, Cerner's team exemplified the complexity of a delivery system in its various contracts. Just image each contract with its own episodes and each with its own quality reporting requirements. It does not take many episodes before the informatics systems are overwhelmed and unable to create meaningful dashboards for the delivery system to manage. Add in payer obligations like meaningful use or prior authorization logic or revenue cycle denials and on and on. Very quickly, a business system loses all hope for efficiencies.

How can we fix this? Through standardization. The industry standardized coding using CPT and DRG. It standardized billing using CMS 1500s. We need to standardized data exchanges for interoperability. And we need to standardize episodes, bundling methods, billing methods, care models, quality outcome measures and more.

To move to a modern age for managing all the knowledge we have and to leverage machine learning and AI will take a complete rethinking of healthcare - beyond fee for service and beyond simple knowledege. Our health and healthcare are complex and deserve more than we have today. By taking these steps, we can enhance care, reduce burden and limit burnout.