by Thomas H. Lee M.D.
What a summer it's been! A veritable harvest of legislative progress appears to have been made by the true farmers of America: our elected representatives. The seeds of change have been skillfully planted, and by the time rainy season comes this November, the legislative fruits of innovation in health IT should just be ripening.
Over the past month, in addition to overriding a veto on the Medicare Improvements for Patients and Providers Act, Congress has been busily crafting legislation to more broadly promote the adoption of health IT. One proposal, HR 6357, is being reviewed through the House Energy and Commerce Committee, while a delayed alternative has arrived courtesy of Rep. Pete Stark (D-Cal.) and the House Ways and Means Committee.
Rep. John Dingell (D-Mich.), Chair of the Committee on Energy and Commerce, used this analogy in arguing for HR 6357 (warily or wearily known as the PRO(TECH)T Act):
"Your grocery store automatically knows what brand of chips you bought last year, but your cardiologist doesn't automatically know what prescriptions your family doctor prescribed for you yesterday. That's problematic for health care quality and costs."
True. But scary. On multiple fronts. Least frightening is the fact that Safeway can readily ascertain that you bought 32 bags of Ruffles brand potato chips last year, a 22% increase from the year prior. More concerning is the surely unintentional but problematic suggestion that it's OK, if not preferred, for your grocery store to automatically know everything about you and your penchant for junk food.
But perhaps most problematic is the notion that Dingell and other legislators may actually use such analogies to help clarify their thinking and/or sell legislation aimed to promote health IT.
Deceptive Simplicity
The reality is that analogies, though they can often elucidate complicated concepts, have the potential to be equally dangerous instruments of distortion. They're easy to grasp, easy to remember and, therefore, easy to delude. The beauty and curse of some of the best analogies are that they often oversimplify or create emotional similarities that don't actually reflect reality.
Taking a closer look at Dingell's analogy, the unstated subtext of his statement is the following: "Even something as basic as grocery stores is able to track and use data about you. So why shouldn't your cardiologist? This health care IT bill will help foster that change and therefore improve quality and lower costs."
At the surface, it's certainly difficult to disagree with something so simple and apparently rational -- thus, it's effectiveness as an analogy. But let's dig a little deeper. Are grocery stores really that "basic"? The underlying and unstated assumption is that grocery stores are unsophisticated. The reality is that today's commercial grocery store chains are quite the opposite. Companies from Whole Foods to Safeway and Wal-Mart are multibillion-dollar, publicly traded entities with robust supply chain management systems and pricing/point-of-sale systems to ensure that stockouts never occur and profits are always maximized. Should we hold the same expectation of your local cardiologist?
Furthermore, let's assume that the health IT bill actually did foster IT adoption, even to the sophisticated level of grocery stores. Does that really mean that the cardiologist would be able to track prescription data written by your family physician?
Again, highly unlikely. To take the analogy back to grocery stores, we'd have to ask the question: Does Safeway know what products I bought yesterday at Whole Foods? In the absence of collusion or espionage, the answer is likely "no."
What Dingell's analogy unintentionally disguises is another key dimension to the problem, which is that distinct (and particularly competing) entities don't share information with each other. Even if they wanted to share data, this would be a very complicated endeavor. Safeway and Whole Foods certainly don't carry the same SKUs (e.g. Ruffles) nor do they share the same data and tracking systems. Such an integration would likely be a multimillion-dollar outsourced consulting project.
So, in retrospect, the analogy would have more closely reflected reality if it had been stated as follows:
"Your big, profitable, sophisticated grocery store chain knows what brand of chips you bought last year but has no clue about your other consumption habits at other stores. So, to ask your local 'mom and pop' cardiologist to develop and integrate expensive ERP systems with your 'mom and pop' family physician is an impractical if not impossible request. This health IT bill will ultimately not generate the cost and quality outcomes we'd hope for, but it's a start."
Analogy in Health Care
Does this mean that all analogies are problematic? Should we do away with metaphor and simile altogether? Certainly not.
Given the right context and construct, analogies can be enormously helpful in clarifying new concepts. But the key issue is that the context and construct need to be highly related and similar. Sophisticated, large grocery store chains that are working in a free-market environment are not even remotely similar in context to small physician groups working in a fixed, third-party reimbursement system. By comparing the two, we are only setting ourselves up for false hope and distortion.
To use analogies effectively in health care, we need to find markets that are more closely similar in context to our own. Unfortunately, these are few and far between -- especially when it comes to finding analogs for health care delivery organizations.
Public schools, local accountants and not-for-profit groups come to mind in that they share some or all of the following features: service industry, local markets, regulatory constraints, third-party reimbursement and tight limitations on what the market is willing to pay. But, as you can imagine, these aren't the sexiest or most familiar of analogs.
So, the reality of analogy in health care is that it's difficult and often uninspiring. The industry is a victim of its own complexity and, if anything, we'd be better off working on making the system more simple, transparent and effective. That may be through fostering adoption of IT, or it may be through other means such as finance reform. But to continue sponsoring new bills fostering or mandating the adoption of health IT, particularly positioned as a panacea, is overly simplistic and a disservice to real change.
In some ways, today's health care IT bills are like a bucket of raw oysters. They're popular, alluring and even tantalizing but rarely does one find a pearl of true progress inside. And if we end up eating too many of them, we're likely to just end up getting sick.