Monday, March 30, 2009

Health care jobs

Let me add a bit more to my argument that President Obama, for all his good intentions to control health care costs through computerization, is missing some of the more important aspects of the transition. As I've written before, there seems to be a theory at the White House that pumping money into getting medical records from paper into the computer will: cut costs markedly, decrease life-threatening errors, and create (or, in the strange and unquantifiable term, "save") jobs.

I'll dispense with the second item first, if only to say that I have no idea to what extent computerization will save lives. It's pretty easy to posit situations in which that will help; for example, in caring for an elderly person who can't remember their drug sensitivities. This all sounds good, to imagine a system in which test results go directly from the lab into the Multivac, available for all downstream health providers to see.

Of course, there are also some massive security and policy issues, and I have no idea how we'll deal with that. As it is, we go to the doctor's office and routinely sign our HIPAA form, but with only the vague sense that we're giving access to the people in that office. How will we feel when we realize that we're letting anyone who has access to the system around the world see the details of our care? And we'll have to do that to make some of the more rosy scenarios come to pass. If we want the French paramedic to be able to treat us optimally at the scene of our car accident, they need to be able to look at our health history. (In a world where we allow offshored mortgage processors access to our financial statements, maybe this isn't so much of a concern.)

To put a financial value on this right now is almost impossible - our data is weak when it comes to understanding just how many people are injured or killed due to a lack of the information that would presumably be available. And I need to stress that, all things being equal, I'm very much in favor of this kind of initiative. I'm just trying to explore whether we can expect all the gains that have been promised.

As for my first and third points, at first blush they seem incompatible. We all know that the major component of any business expense is personnel (at least that's what we're told when the heads roll). If we're cutting costs while preserving or expanding jobs, then there must be some magic expense that's hidden in the health-care system that has nothing to do with people.

Because the money that will be saved comes directly from letting go of the people who handle the paper. I go to my doctor's office, and there are a whole lot of non-doctor people drifting around, more than seem necessary to answer the phones or take my blood pressure. Of course that's because many of them are handling paperwork, whether it be patient records or insurance forms. Automate that and, for better or worse, those people are gone.

The point might be raised that these people will transition into the new health care jobs that will be creating by this vast modernization project. And here's where the details get in the way of the theory.

I've been involved with several projects that take a paper-based way of accomplishing something and put them on the computer. Here are the jobs that come during this process: subject matter experts (SMEs) who create the specs for the new system, designers and developers who create the new system, and clerical support that somehow gets old records into the new system. There are some ancillary jobs, managers and testers and the like, but these would be the three major categories.

So we have two questions: where will the "old" people fit into this process, and who exactly will get jobs in each of these categories, that is, how much will this big-P project actually enhance the employment situation for Americans?

Unless there are some closet programmers in the ranks of the support staff at my doctor's office, their new jobs will have to come as SMEs or scanners. But there is no way that the staff to SME ratio is one-to-one, the SMEs will tend to come from the ranks of the most senior office staff. Because this is to be a national system, there will be relatively few experts enlisted in setting the specifications.

And few of these trained staff people will want to move to the scanners. That will be mind-numbing work, whether it consists of literally scanning in massive paper files or retyping a doctor's chicken scratches. (This is also the place where compromises will be made for time and cost considerations. Dead people are unlikely to get computerized records, and there may be an attempt only to get the last 10 or so years into the system.)

Furthermore, these jobs will either pay very little, or they will be outsourced (or, maybe, offshored?). This is public money, so there will be a lot of pressure to "Let Brown Do It," to ship boxes of medical records to a concrete-block building in North Dakota (or Bangalore or Manila) to be converted into a new file format.

Essentially, these jobs will be lost in the interests of efficiency, and that might be a good thing in terms of productivity. But it seems at odds with one of the major goals of the program.

Here is the place where I can reiterate my earlier point that even the hard-core IT jobs are unlikely to create a job boom for Americans. The offshore BPO (business process outsourcing) firms are reportedly already buzzing around this business, and I really don't see how we'll be able to withstand the cost differential. If I had to guess, I would say that very few jobs will actually be created in the U.S. to build the system. There will be a few - UPS may be able to add some people, and we'll need some technicians for installation and training - but it isn't even clear that the number will come close to the jobs that are lost.

Once again, we should embark on this effort; it only makes sense that a modern country has modern medical records, and there will undoubtedly be gains in safety and efficiency. But let's not fool ourselves that this can lead to a jobs boom, there is absolutely no evidence for that.

[Note: I have omitted other issues here, such as legal liability and the false certainty of "it's on the computer, so it must be right." These are potentially large, absolutely non-trivial, and perhaps they'll find their way into another post one day.]


Citizen Carrie said...

There are so many aspects of health IT it is almost impossible to talk about the suject without being way too narrow in scope. My biggest concerns involve input and output. I'm lucky to have doctors who really take their time inputting everthing carefully and accurately into the PCs. When they're in the examining room, they spend most of their time typing away. I fear there might be other doctors who meet with patients, jot a few notes, then tell assistants to input the notes into the system. Since these assistants are not present during the examination, I fear a lot of valuable information will be lost.

As far as output, I'm sure the systems will have all of the necessary information just waiting to be accessed. Based on what I see, health care professionals mostly only give a cursory glance over the information before meeting with or treating a patient. (And I realize that health care professionals don't have the luxury of spending 30 minutes reviewing notes every time they come across a new patient.)

As far as privacy, I smile at the thought of the people I know who talk forever about their bunions and gall bladders to everyone they meet, but get all indignant at the thought of having the same information input into an IT system. The biggest concerns I see involve employment and the availablity of insurance and loans based not only on your health history, but any family health history that might be recorded.

As far as cost savings, I imagine installing health IT systems will be about the same as spending money on home improvement projects. When you get new energy efficient windows and appliances, do you immediately notice a huge difference in your utility bills and bank accounts? (I suppose if you live in a region that has roughly the same temperatures year-round it might be easier to notice a difference.) Chances are, if you live in a true four-seasons region, you don't really notice any savings right away because of issues of actual versus estimate utility readings, constantly changing weather conditions, etc., not to mention that you're still paying off the home improvement bills. With all of the improvements that we've made in our house, we've never been able to take our "savings" and really budget it for other uses. We know we're saving money, but it's not readily apparent.

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