Fixing healthcare workflow

Beyond policy debates pre-pandemic, the overall focus for U.S. healthcare improvement generally centered on technology. Figuring out how to better digitalize the sector and leverage advances in computation and connectivity generates enormous investment and innumerable new products, tools, and services.

While modernization remains a driving concern, in the post-COVID-19 world, it should address an issue revealed to be critical: workflow.

A workflow is simply defined as the sequence of processes (industrial, administrative, etc.) through which work passes from initiation to completion. And by that definition, if there is any lesson we can already draw from this still-evolving health crisis, it’s that the U.S. healthcare system has some serious workflow problems.

The provision of healthcare requires both scientific rigor and a reliable system of support and oversight, but our existing methods for meeting those needs can impede delivery and derail effective function. The pandemic’s arrival in the U.S. surfaced a litany of conditions where healthcare workflow just doesn’t work.

The fragility of globalized supply chain “efficiencies,” for example, resulted in widespread shortages of essential healthcare materials — personal protective equipment (PPE), ventilators, chemical reagents required for testing — exposing an appalling lack of resiliency in our procurement networks. Inflexible operational structures and labor distribution mechanisms created problems as well, as some emergency rooms and ICUs were relentlessly overwhelmed, while other facilities furloughed workers and sat idle. Functionally unsearchable electronic medical/health record (EMR/EHR) systems prevented doctors from “identifying effective approaches to a novel disease” and laborious authorization bureaucracies met virologists in the crucial early days of emergency response. Further, a decades-long boom-and-bust cycle in research funding “perpetuated gaps in the scientific understanding” of coronaviruses, leaving us playing catch-up on treatment, transmission mitigation, and vaccine development.

The sequence of processes coordinating material, personnel, tools, governance, funding, and knowledge — which together form the U.S. healthcare system — too often failed when and where most needed. The work did not flow.

There is no one-size-fits-all solution to addressing these shortcomings and those advocating quick fixes are denialists choosing to ignore the very real and necessary complexities involved healthcare delivery in the U.S.

Technology, for example, is not a panacea: It can either help or hinder depending on how it serves the healthcare workflow. Consider how physicians frequently come to view supposedly helpful EMR/EHR technology as an impediment to practice. As Dr. Atul Gawande wrote in his brilliant 2018 article Why Doctors Hate Their Computers: “I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me…Something’s gone terribly wrong.”

Shiny new tools come with consequences that impact the entire sequence of processes for good or ill. A recent Nature article demonstrated the myriad considerations involved in incorporating just one class of new technology into a healthcare workflow — and the lack of a standard existing framework for doing so safely, which should address:

• Clinical validation
• Security
• Data rights and governance
• Utility and usability
• Economic feasibility

That’s just a suggested framework for ensuring new tools serve workflow as intended. The people using the tools face even more demanding challenges, as workflow is also often hindered by entrenched behavior. The Institute for Healthcare Improvement’s Dr. Don Berwick suggests we must speed our pace of learning, acknowledge the value of standards to reduce wasteful variation in care, and confront the inequalities that pervade our system as well.

Distorted cost and payment structures also impede overall healthcare workflow, focusing resources in areas that don’t necessarily contribute to better care delivery. The standard fee-for-service model has proven problematic and bloated administrative costs have risen to a mind-boggling 34% of total U.S. healthcare expenditures. As the late healthcare economist Uwe Reinhardt detailed in his final book Priced Out: The Economic and Ethical Costs of American Health Care, “No other developed country spends nearly as much on the administration of health care as the U.S.”

But better healthcare workflow doesn’t require summarily scrapping everything we have and building something entirely new. For example, we have powerful existing technologies that simply aren’t effectively utilized because misaligned incentives discourage it. As a case in point, telemedicine technology has been around for years, but adoption didn’t really take off until the pandemic arrived, and the government updated CPT codes for telehealth to support physical distancing strictures. There was no technological innovation involved in the surge in adoption, it was driven by a practical policy change that made usage feasible.

Re-evaluation can work wonders. Addressing obstruction with experimentation and adjustment can serve to boost healthcare workflow and ultimately deliver better care.

Such has been the case with some innovative business models. The Long Fix author Dr. Vivian Lee recently spoke with the Commonwealth Club about encouraging results in improving healthcare delivery through novel value-based primary care business models that have produced better health outcomes, reduced hospitalizations, and ultimately reduced costs. Bundled payment models for hospital systems or global budgeting as practiced by the Veterans Administration also show promise in removing adversarial incentives and promoting more cooperative workflow, according to Lee.

Ultimately, if we want a better healthcare system, our workflow should prioritize the desired result of our sequence of processes — which is better health outcomes. What helps the physician deliver care, and what helps the patient receive it?

Reassessing how each process fuels that goal might clear a lot of blockage.

Lawrence Cohen, PhD, is a biotechnology expert and CEO of Health2047, a business formation enterprise that works in partnership with the American Medical Association to find, form, and fund system-level solutions to healthcare’s biggest challenges.