DECISION

A DECISION is a choice about something after thinking about it.   Choosing not to decide, procrastinating, or choosing to wait for more input to consider is also a DECISION.

I could go in many directions to write about DECISION concepts but I would like to focus today on if and how focusing on the DECISION can be a foundational reform for health care system challenges.

And let’s make it interactive – I would be interested in your comments this week on these concepts.   This could be relevant to you if you will ever use health care services.

First, a little background for any reading this who may not understand how health care is paid for today.   There are many variations but the US government paying through Medicare is a large shaper and many other systems follow similar patterns.   And Medicare does not pay directly for “actual health care” – how would you define “actual health care” to know how to pay for it anyway?

But we can think of health care services as a combination of four factors to make it relatively simple:

1. OBSERVATIONS – the health care professional asks you about your concerns and past experiences to observe your answers, examines you to observe things like swelling or rapid heart rate, and looks at tests to observe the results – there could be hundreds of things the clinician observes to deal with a single health care concern
2. DECISIONS – Based on all the observations about you, and ideally combined with all the observations about everyone else providing information on what to expect (we call that evidence), the clinician will decide what to do (tests to obtain, interventions to prescribe, advice to share). For many DECISIONS you likely want to be involved in the decision-making.  I started this year with posts leading up to a major goal of seeking WISDM: Well-Informed Shared Decision-Making
3. PROCESSES – The health care professional engages in actions to document the observations and DECISIONS and implement health care services. Processes can include things like scheduling a follow-up appointment, prescribing a medication, performing a procedure.  The processes are often what we think of in terms of receiving health care services.
4. OUTCOMES – Ultimately the reason for health care services is to achieve better outcomes – lower mortality, fewer symptoms, avoidance of preventable adverse events, improved function. When these outcomes are difficult to measure directly we sometimes consider surrogate outcomes that are easier to measure that we hope will be a proxy for the important outcomes.

Health care services take time to provide but paying for time (an approach used in many professions) was not applied as the primary method for Medicare to pay for health care services. Although suggested as a reform there is substantial mistrust that paying for time will lead to desired results.  Instead health care payments are primarily based on OBSERVATIONS.   To bill Medicare for services rendered there is an expectation of documenting OBSERVATIONS pertinent to the services rendered.  Auditing payment of health care services has become a large system for designating the type of OBSERVATIONS, and numbers of and combinations of these OBSERVATIONS to justify payments.  Electronic health records grew with a primary business driver of collecting these OBSERVATIONS to support billing and payment functions.

It is no surprise that the volume of OBSERVATIONS is not the most important factor in health care and that such a system leads to many unnecessary OBSERVATIONS (perhaps necessary for billing but not necessary for health care provision), does not require or emphasize the necessary OBSERVATIONS, and shifts huge resources away from other activities to gather, document, and check for conformance across all these OBSERVATIONS.

So we don’t get the desired results from our health care system.  The next stages of health care reform, attempts to improve upon this, jump to PROCESSES and OUTCOMES.  Let’s measure the desired PROCESSES and OUTCOMES and call that QUALITY.  Then let’s set aside a portion of our health care payments and increase it for better QUALITY and decrease it for worse QUALITY.   If we can do that then the system should get better as everyone is incented for better QUALITY.   There are serious challenges with this approach, especially because there is little agreement in defining QUALITY.  Professionals are not consistent in what they believe to be the optimal PROCESSES and surrogate OUTCOMES, and when they are these goals may not be consistent with what matters for individual patients.  So we can create large systems to chase the wrong PROCESSES and OUTCOMES.

We now have large datasets amassed to view all the OBSERVATIONS (considered important for documenting for payment purposes) and view all the PROCESSES and OUTCOMES (selected for measurement as the way quality is being defined).   This system does not directly or easily inform what is most important for a specific patient or why.  You can imagine why a health care visit is often seen as clinicians putting more and more time into data entry and less and less time into health care.

Somewhere in the midst of all this the DECISION was all but ignored.  There are few areas in health care where documenting the DECISION occurs.  Try figuring out why a patient on multiple medications is taking those medications, and if they considered the benefits and harms for those choices.   Try finding the individual goals for a patient to inform decision-making.  These are not typical parts of our health care records.

WHAT IF OUR HEALTH CARE PAYMENT SYSTEM FOCUSED ON DOCUMENTING THE DECISIONS RATHER THAN DOCUMENTING THE OBSERVATIONS?

To be clear I do not mean having the health care system define the “right” DECISION and paying for that – leave the determination of making the “right” DECISION to the professionals and to the patients who have the largest stake in determining what is “right” for them. 

But if the system paid for documenting the DECISIONS could the following occur?

• Obtaining and documenting the OBSERVATIONS needed for DECISIONS increases while large efforts and systems for unnecessary OBSERVATIONS decreases – shifting our attention to what matters on a large scale
• Increasing the likelihood of PROCESSES and OUTCOMES that matter because we are clear on DECISIONS about what matters
• Increasing usefulness of the electronic health record because it tells us what matters for a given patient – the “story” is better documented when looking back to see what happened
• Greater focus on DECISIONS in the health care encounter which seems like greater opportunity for clinicians and patients to communicate about what matters

What do you think?  If we could change our system to pay for documentation of DECISIONS (not dictating what the DECISIONS should be) rather than documentation of OBSERVATIONS would that be a basis for major health care reform.   Do we need to think differently about health care at such a fundamental level?  Is this a DECISION we can make?