Gary Oftedahl: Excavation in a time of Innovation

There is a huge need in the health care arena for new ideas, new concepts, and the ability to implement these efforts into the system.  A word freely thrown around is “innovation” and the opportunities for health care to be transformed through use of that concept.

Innovation implies not only a new idea, new technology, or new process, but an associated scalability (it’s bigger than a breadbox, and has capacity to fit more than isolated pockets of acceptance), as well as an economic model which enhances the likelihood this will be sustainable.   While in the past, we’ve piloted many new ideas, and used grant or extrinsic funding (“funny money”) to support these efforts, the bitter experience of seeing the successes enjoyed founder once the funding evaporates leaves all of us who’ve experienced that skeptical of moving innovation forward again.

Indeed, at recent meetings at NIH, as well as SAMHSA, it was frequently pointed out that the ability to engage organizations in piloting new care models, in the absence of any substantive discussion of what financing model is needed, is unlikely.  Those of us committed to quality improvement, testing new processes, engaging our peers in attempting to change practice patterns have many scars, and carcasses of well-designed, well-constructed, well-executed efforts to show.

So it’s my hope that the recent frenzy surrounding health care redesign, especially with regard to the patient-centered medical home concept, will not be lost in a haze of euphoria over the potential for this concept.  But, as I’ve voiced before, we should move with a “speedy hesitation” in proclaiming success until we’ve truly gained an understanding of the elements that are in need of economic support to maximize the likelihood of their sustainability.

But there is another needed effort, in moving our dysfunctional system toward transformation, that in my mind is equally if not more important than the innovations I see being contemplated.  What about the “excavation” we need to see?  We’re already an incredibly complex system, layering on new ideas, new technologies, new processes—that’s part of the innovation.  But we continue to support, both culturally and financially, many practices which we clearly know add no value, and, in fact, may actually cause harm.  So as we “innovate” and add new processes and ideas, let’s on a parallel track begin to remove the support for all that is wasteful in health care.

What might that look like?  The list is endless, and I’m not likely to be comprehensive, but what if we eliminated the artificial (at least in my mind) separations and “carve outs” seen in our health system for mental health, substance abuse, and the traditional biomedical elements?  Whoa, I see a few hackles arising out there, but this artificial duality (or perhaps triality) does little to recognize the need for wholeness, and appreciate the patient as more than a compendium of clinical conditions.  How much redundancy, misunderstanding, and missed opportunities would be accomplished by such an elimination?  Of course, the challenges are huge, but innovation, without an associated “excavation,” is unlikely in this regard.

What if we stopped paying for all the proven unnecessary tests, procedures, and processes, which are identified as inconsistent with the evidence?  I’m a little gun shy here, as I’m well aware that more than 60% of patients view limiting coverage to those which are evidence based as an infringement of their right of choice–but that shouldn’t preclude us as professionals from addressing this issue.  How many unproven screening tests lead to unnecessary and often damaging consequences–both physically and psychologically.  As we continue to pay for PSAs, routine chest X-rays, multi-panel blood tests, and innumerable invasive cardiac procedures proven to not add time or quality to life, we are not truly confronting the issues which we face.

This is only the start. I’m sure you have many other examples.  But as we embrace innovation, and excitedly begin our journey into new ways of improving the health of our communities, it would behoove us to actively begin the process of “extraction” and eliminating the things we know haven’t worked, but are embedded in our culture and workplace.  Am I wrong, or is there something I’m missing?  Can you see opportunities for such efforts in your workplace, community, or state?  I’d love to get your thoughts, or if needed, an attitude adjustment on my part–after all, perhaps my opinions and views are in need of some “excavation” also.