If You’ve Got a Hammer, Everything Looks Like a Nail

I remember hearing this expression all the time in med school from non-surgeons when they described surgeons, especially orthopedic surgeons for some reason (I guess the mechanical nature of ortho lends itself to hammer-and-nail comparisons). It applies to all areas of life, but for some reason I don’t recall hearing it until I got into the world of medicine.

Looking specifically at medicine, the statement rings true as a source of potential problems as docs become increasingly specialized and see patients through very specific filters. As an absurd example (not sure this debate is still going on), pediatricians want kids to see the sun periodically and dermatologists think kids should take vitamin D supplements but avoid sun exposure. There’s a movement toward patient-centered medical homes (PCMHs), which ideally would solve some of these specialty filter problems by having a PCP at the center of care, with the PCP coordinating recommendations and care plans from various specialist consultants. Technology can help enable and empower PCMHs, and I’d go further to say that good technology is essential to functional PCMHs. I also think we want to consider building this core thinking into training physicians, both PCPs and specialists, and I don’t think the current programs are sufficient for this.

But this post isn’t about PCMHs or the potential problems presented by our super-specialized medical force. This post is about health technology, and specifically connected health technology, as it relates to the care and wellness of patients. I alluded to this in my last post, when I discussed HIMSS vs. my wife’s clinical conference immediately preceding HIMSS. The problem that was very apparent was the misaligned and sometimes misguided resources.

There are lots of players in healthcare and each carries their own hammer. Pharma wants to solve problems with meds, though it is transitioning or at least testing the waters with health technology solutions. Pharmacies think retail clinics are the key to reforming healthcare. Informaticists, and more broadly health technologists (is there a clear distinction between these terms?), bring the technology hammer. Mobile developers think mobile apps are the key. Electrical engineers love sensors. Analytics love big data. There are probably a lot more of these, but you get the point.

As an example, if you’re an iOS developer and you look at healthcare, you see that mobile apps have huge potential to help patients monitor themselves, get tailored and timely recommendations, and connect with others to help them with their health. And you believe strongly that clinicians and health systems should be prescribing apps, and hopefully your app makes it into the app formularies.

If you’re selling an EMR — or potentially if you’ve installed and presumably paid the equivalent of a developing country’s GDP for an EMR — you might see the EMR as the hammer that can engage patients, improve collaboration and communication, analyze big data, and probably a few other very impactful things. Unfortunately I think that’s not the case. Your EMR, whether you own the code or the license, is not going to solve most of those problems. Even if you have apps in the pipeline for release in the next few years, you’re not going to solve all these problems. Outside of healthcare, enterprises are moving towards modular models, with offerings and integrations of things like Box, Yammer, and even Google Apps. As I wrote earlier this week, the EMR might serve as the foundation for some of this in healthcare, but I think the foundation is the best case scenario for EMRs.

Interestingly, clinicians (nurses, docs, etc.) bring a variety of hammers, but essentially clinician hammers all boil down to delivering care and getting paid for it. Care is largely based on judgment today (it’s got some flexibility), judgment that the pharma companies and more and more the health tech companies will influence. What are clinicians supposed to do, and I’m talking about the vast majority that don’t straddle clinical and technology? Most clinicians spend whatever intellectual energy they have staying up to date on clinical practice, not reading this blog or any other sources to learn about all the new technology that a massively growing industry is building to help them take better care of their patients.

But wait, are we building all these new apps and mobile services to help clinicians care for patients, or are we building this technology to solve problems in ways that don’t fit with our current care paradigms? I vote for the latter, and that’s why paradigms in care have to change. But it’s also why clinicians need to be a part of it, because we’re not going to replace 80 percent of them anytime soon.

I also think that most clinicians tend to use their own lens as clinicians to overvalue the doctor-patient interaction and their place in the wellness of patients. There is an art to being a good clinician — healthcare is not just a data problem — and I firmly believe in the value of the doctor-patient relationship. But gone are the days of old when docs cared for patients longitudinally, and some things need to change in how clinicians and patients interact.

Fundamentally changing the way clinicians and patients interact is going to take time. It won’t take 50 years, but it’s not going to happen at scale in the next 5-10 years. That’s why I think we need a middle road, because it is going to take a long time to change the direction of this massive ship called healthcare (sorry, I’m really into analogies this week). Tools to bridge where we are today to where we want to be require different stakeholders to talk to on another and share experiences so we can collectively come up with solutions for today’s health system and today’s patients.

As I’ve read over the last week, 35,000 people met in New Orleans last week to share and learn how to utilize technology to improve our healthcare system. That’s amazing! That’s awesome! But probably every week throughout the year there is a meeting of some clinical organization where thousands of people gather, many of whom are actually caring for patients today. These thousands of people, by and large, want to accomplish the same thing — delivering better care to more patients.

I never meant for this to be an HIT kumbaya campfire post. I realized as I was writing that what I was really trying to say is we all need to see that we’re trying to hit the same nail, and maybe we need to better appreciate the hammers we all bring the campfire. How’s that for way too many analogies in one paragraph?

Travis Good is an MD/MBA involved with health IT startups. More about me.

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