May 17, 2013
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Policy-makers are going about healthcare quality improvement all wrong. They are focusing too much on physicians rather than on the behavior of patients that lead to so much illness, according to a longtime advocate of telemedicine and telehealth technologies. But practitioners also need to let go of the attitude that they know what is best for patients, said Johns Hopkins School of Medicine physician Dr. Jay Sanders.
"The real change we need to effect is the consumer," said Sanders, who, as president and CEO of McLean, Va.-based The Global Telemedicine Group, chair of the technology board at Vesalius Ventures and a founding board member of the American Telemedicine Association, is widely known as the "father of telemedicine."
He said so many reform efforts are aimed at changing physician behavior when the patient is the real barrier to better health. "They never look in the mirror and see the No. 1 problem," Sanders said of patients. "It's not the doctor's fault that the patient continues to smoke or eat cheeseburgers every day."
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For this reason, Sanders is no fan of the idea of pay-for-performance. "What a ridiculous program," he scoffed in a recent interview, explaining that such ideas penalize doctors for the unhealthy habits of their patients. "I look at them as taking money out of my pocket because of their behavior," Sanders said.
Instead of penalizing providers for the unhealthy habits of their patients, Sanders said the health system should provide incentives to get healthy -- which many companies and payers offer as employee and member wellness programs. There also can be a "stick" in the form of higher insurance premiums for people who do not take care of themselves. "We need to get the patient to embrace it," Sanders said.
Sanders sees the requirement in Stage 2 Meaningful Use that 5% of patients log into and upload data via a portal or personal health record in the same light as pay-for-performance. "It's putting the onus on the physician for the patient's behavior," he said.
One form of telehealth, namely remote patient monitoring, could go a long way to making patients and clinicians alike more aware of health problems, according to Sanders, who chairs the Federal Communications Commission's Rural Health Care Committee and is on the executive committee of the board of directors of the Friends of the National Library of Medicine.
"We need to bring the exam room to where the patients are," Sanders said. Taking blood pressure in the sterile, confined environment of a clinic fails to replicate the stress people face in the real world, he explained. The same is true with measuring lung function in a medical office. "They're not breathing the air in our office all day," Sanders said.
Sanders also said the national push to computerize medical records has not made much of a difference in terms of better quality because there are no true standards for practicing medicine. "I often say in my talks that the electronic medical record is dangerous to your health," noted Sanders, who spoke at the ATA annual conference this month in Austin, Texas. "Nobody is looking at the integrity of the data acquired."
Additionally, physicians still skate by on their credentials and their reputations, in no small part because patients judge doctors on name only. "That's Jay Sanders. He's professor of medicine at Johns Hopkins," Sanders said somewhat mockingly of his own reputation.
"There is a reality that many of my colleagues have trouble accepting, and that's the fact that there are no standards," Sanders said. "Each individual doctor is his or her own standard."
Physicians simply cannot and do not stay up to date on changes in medical knowledge without clinical decision support, he noted, echoing what health IT pioneer Dr. Lawrence Weed has been saying for close to 60 years.
"The way you bring collective expertise to the bedside," Sanders said, "is to use predictive analytics and use artificial intelligence."
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