Saturday, 11 October 2014

Ebola screw-up and big data health capitalism

Entirely without premeditation, I find I have taken a break from commenting on our biped species’ determined rush toward oblivion. I did take a two-week vacation and then commented on it for another week afterward, which was very restorative and felt self-indulgent—lingering Calvinism, no doubt. It is a bit surprising, though, to see how long it has taken me to refocus on the many ways in which humanity drives forward unrelentingly toward the multiple precipices of its/our own creation. I now feel sufficiently retoxified to resume.

Incidentally, however, I must express, albeit in the form of cliché, an observation: our disappearing world contains many marvels, which remain a source of delight.

The latest episode in biped self-immolation is the dysfunctional response to the first Ebola patient, a Mr. Duncan, and the continuing attempts to ignore the lessons that could have been learned by those mistakes. This careful review from Health Care Renewal points out several aspects that drew my attention. As many have noticed, the patient’s recent visit to West Africa was not communicated to other medical staff, and he was discharged despite having a high fever.

So far this is not rocket science: the man was black, uninsured and in Texas. What facts might be missing here? Is there some reason why he would NOT be promptly discharged onto the street given that the hospital could not make any money off him by ordering more tests or keeping him overnight as a mere sick human being? What minimally educated MBA hospital administrator would not applaud a nurse for getting this useless element out of their pristine medical facility toot sweet?

Now obviously there is a special circumstance here in that the fact of a dangerous infectious disease epidemic outbreak is hardly a secret and should have alerted anyone in the health field, especially including ER staffs. Although Texas might not care much about a penniless African immigrant, his microbes could have infected prosperous white people. Why didn’t the information about his travels get passed on?

Here we run into the modern fetish of electronic everything: the nurses might well have overlooked entering his crucial travel data into their computerized medical records. The article linked to above quotes an interview with the hospital corporation’s Chief Operating Officer, Jeffrey Canose. (The company is called Texas Health Resources, which I find a curious choice: “health resources “could mean things like gauze and doctors, of course, but I suspect they mean something more like a vein of ore to be mined.)

The biggest challenge is to continue on our journey to increase our capabilities as a fully integrated health system; to develop the competency to be a high-performing system in the realm of population health management; to shift our focus from sick care to actually managing well-being. . . .

Aside from the unctuous, business-school prose (“continue on our journey”), this bland rhetoric masks a ruthless business plan: how to collect premiums while not paying for people to be cured (“sick care”).

Now, “managing well-being” sounds innocuous enough. It could mean more attention to preventive health actions—who could object to that? On the other hand, it could (spoiler alert: does) mean figuring out who may need expensive services down the road and figuring out how to avoid paying for them.

How do they plan to go about doing that? Mr Canose tells us:

. . . people in IT are mission-critical partners in hearing what kinds of problems we’re trying to solve and in helping us to figure out how to drive clinical transformation and care design, and how to drive efficiency. . . . the electronic health record is a huge enabler to all this; the next challenge will be to enable things further, including through data mining, working with big data and clinical and operational support.

Why all the attention to IT and “big data”—meaning amassing huge numbers of medical files on all of us to detect patterns? (“Why do you have such long teeth, Grandma?”) Why, to better extract rent (“resources”) from the health care apparatus, my dear.

Anyone even marginally close to primary or emergency care as currently practiced, as I am, will immediately recognize what Canose is referring to: the requirements imposed on all providers from the moment a patient walks in the door to gather a slew of data on that person, which is fed into the maw of hospital computer servers. Ostensibly, it is designed to improve patient care, and it may have that effect in some cases. But we have all become bits in a database, dependent upon the carefully pre-pacakaged and pre-priced services to which we are entitled according our place in the system (and contribution to it). The hospital needed Mr. Duncan’s vitals and data on his health history and personal habits to beef up the statistical power wielded by its analysts so that Mr. Canose can sit in his office and calculate the health, illness and cost probabilities of a million future patients.

But in the rush to nail down what the system needed to “continue on its journey” toward greater shareholder profits, salient facts about Mr. Duncan were either ignored or not flagged because “recent travel to West Africa” does not appear in any of the complex algorithms related to extracting rent from health care. Given that the lesson of this major goof, if acknowledged and digested, would complicate the economics of our entire system, we can be fairly confident that it will NOT be learned. Ebola-specific errors may now be corrected as long as the attention remains high. But the broader indictment of how profit-making is undermining health outcomes will be studiously ignored.

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