The recent financial crisis highlights the need for social service agencies to do more with less funds. Meeting that enormous challenge requires significant innovation in the way that hospitals, clinics, schools, and other social organizations serve their communities. The recent financial stimulus package calls for billions of dollars to be spent converting hospitals and clinics to use Electronic Medical Records (EMR) systems. Billions more will be spent on charter schools and other attempts to improve education. In spending these huge sums, the administration hopes to save money in the long run and provide better education for Americans.
Good care requires freely accessible infrastructure for sharing information. The ServiceLink project led to the SharedRecords service, an innovation in how community organizations can simply and securely share information.
We all hope that the administration’s efforts will succeed and the money spent will be considered a good investment by future generations. Unfortunately, experience shows that you can’t always buy the best ideas especially in social services where we don’t have good ways to measure quality, set prices, or even really understand what might be meant by supply and demand. Consider health care costs, where several studies estimate that in the US 1/3 of all medical costs are attributable to administrative overhead. (For example see Woolhandler et al and related discussions in the New England Journal of Medicine.) Much of these costs involve enormous amounts of paper being sent back and forth between providers, insurers, and patients. The current system pits these groups against each other in competitive and often antagonistic relationships where each is fighting for a bigger slice of a fixed number of dollars. Insurers deny claims and force additional overhead onto providers, providers respond by limiting the time they spend on each patient, and patients are left with mountains of debt searching the internet to find somebody who can explain their conditions in plain language. EMR vendors enter this scene with their own competitive goals, gain market share and beat out the other vendors, which create strong incentives for them to create “silos” of data that don’t interoperate well with systems other than their own. They sell their proprietary systems to hospital administrators looking to reduce the cost of billing and increase revenue. Increasing the quality of patient care and improving the working conditions for doctors and nurses gets lip service but doesn’t show up on the bottom line. (Our studies and other ancedotal evidence suggest that EMR systems actually reduce the productivity of physicians who now spend more time navigating around the computer system and less time interacting with patients.)
In this environment, it’s hard to see how subsidizing the purchase of EMR systems will change the fundamental economics of health care. For fundamental infrastructure like gathering and sharing information, I like to use the analogy of roads and waterways. Consider a road between a person’s home and their job. If that road is a public road, anyone can use it and everyone benefits from the reduced cost of transportation. They also benefit from access to services stations and other businesses located along the road and innovations in vehicles built to travel on the road. On the other hand, consider instead a private toll road where the road owner has the incentive to charge whatever the market will bear, control what service stations and other businesses can be accessed from the road, and dictate the terms of travel. (Note Texas is apparently considering using some of the recent stimulus money to build toll roads.)
In the case of private toll roads, most of the benefits of improved transportation are captured by the toll road operator instead of enjoyed by the whole community. In particular, lack of access and barriers to interoperability reduce the overall levels of exchange and innovation in the community and thereby diminish the wealth of the community.
Partly for these reasons, UnaMesa focuses on ways to create freely accessible infrastructure necessary to support team based public services. UnaMesa projects facilitate and support innovation in three main areas:
- data gathering and sharing through flexible combinations of paper, web, and mobile phones
- Example: free SharedRecords service for simple and secure sharing of records between clinics, schools, and other care providers
- cost effective connections between providers and clients
- Example: the Virtual Interactive Classroom that makes high quality, engaging instruction available to students through video and mobile phones
- access to knowledge communities that deliver contextually relevant information through peers and domain experts
- Example: helping the non-profit publisher Hesperian create a 21st century version of “Where There is No Doctor,” a work that has been translated into 80 languages and is the number one requested text for healthcare workers, peace core workers, and community leaders in hard hit areas of the world
Please see our quarterly newsletter for details on current projects.
Recently we’ve been thinking about what more we can do during this time of financial uncertainty to support the rapid adoption of existing innovations that can lower costs while increasing quality. In the US, the SharedCare plan of Whatcom county provides a good example of what is possible within today’s environment. The SharedCare plan uses a combination of Personal Health Records, EMR systems, and local community groups to support cooperation which makes it possible for all the agencies in Whatcom county to share information and deliver better care. One approach to scaling this innovations envisions UnaMesa or another organization purchasing the component software systems and related material on behalf of the community. By so doing, we could quickly make those services available to providers in other communities for free or at very low cost. Other ideas include creating repositories of forms and related business processes so that organizations can easily share and adopt the best tools and practices for gathering and processing data.
What do you see as practical next steps for bringing about fundamental improvements to social services? Do you see opportunities where UnaMesa could make an impact? If so, please comment below or contact me: GregWolff at unamesa.org.
