Earlier this week there was a story on the PBS NewsHour show about a revolutionary new way of delivering healthcare in rural Rwanda.
A company has developed a program to deliver blood products from a central repository out to the remote clinics where they were needed using drones instead of traditional ground transportation.
What once took several hours to get done — taking plasma and blood products via motorbike over dirt roads — could now be done in around 15 minutes.
The medical products were loaded on the drone planes after an order was received, launched into the skies, and remotely piloted to a prearranged location, and then released and delivered via parachute to personnel waiting on the ground.
Not only was this system so cool that it made me want to go right out and buy a drone, but it also gave me pause as I thought about how we’re trying to bring about innovation in healthcare, and how different it is in the environment in which we are working.
Think of the Lawsuits!
Despite all the remarkable healthcare we have at our disposal in this country, all the resources, all the brilliant minds, all the technology, all the almost limitless supply of medications and the like, I thought about what it would try to be like to think about developing a system like this in our country.
Can you imagine trying to deliver blood products through the skies of Manhattan? How many regulatory agencies would have to be involved? Think of the potential lawsuits. Just one misdirected flight, one parachute that failed to open, one pedestrian attacked from above and covered in blood from a burst package, and things would immediately be pulled offline.
But then I think about how hard it is to get a transfusion for our patients within our own practice when we have a fully functioning transfusion center across the street and an incredible blood bank ready to serve our patients.
In the old days, when a patient was found to be anemic and needed blood, we could send them to the emergency room, and they would be transfused and sent home. Then the policies changed, and patients who required transfusions had to be admitted to the hospital, so this became a much less desirable way to take care of our severely anemic patients.
Conforming the Medical Record
With the development of an effective transfusion center, it’s possible for a patient to go, on an outpatient basis, after a type-and-screen has been done, and the orders placed, and receive their blood in a comfortable reclining chair, and then go home.
But at the moment, we are unable to put the orders for transfusion into our current outpatient electronic medical record, so we apparently have to create a transfusion-specific visit in the inpatient hospital electronic medical record, to complete the orders to get our patients transfused.
I can send my patients from my office to get blood drawn, an EKG done, a CT scan, a PICC line placed, and all manners of other tests and treatments, but somehow, getting them transfused remains elusive.
I understand the need for careful checking, careful controls of the blood products, making sure the right patient gets the right blood, that nothing sits out too long or risks contamination, but it doesn’t bode well for ultimately thinking about sending blood through the skies of New York City via a drone so they can be transfused in the comfort of their own home.
These pioneers in Rwanda were thinking outside the box, thinking how to overcome the enormous barriers of the limited infrastructure to deliver the right care to the right patient at the right time, to save a life with the transfusion they needed in 15 minutes instead of a few hours.
Balancing Protection and Practicality
As we continue to try and innovate our own healthcare system, we are working on top of an already complex behemoth of a system complicated by local regulations, hospital policies, federal laws, oversight from multiple agencies, and restrictions from insurers and pharmaceutical companies that often do little to help advance the care of our patients, and sometimes, frankly, hinder it.
While protections are certainly needed, and rules need to be followed, are we really going to move towards a high-tech world of healthcare that is able to deliver the exact care a patient needs at the exact moment they need it? I think all of these other parties need to learn to be more flexible, let us innovate, let us push the barriers and boundaries that for now, at least, seem to stand in our way.
As an example, take our current efforts to move forward with telemedicine. As many people who’ve worked in this area can tell you, it’s certainly not as easy as opening up FaceTime on a phone and offering medical advice.
There are — rightfully — considerations about privacy, interstate commerce, liability, coverage by federal or commercial insurers, how to make one part of our electronic health record work with a different system, how to find the right providers to do this at the right times, the right patients who are interested in this type of care, and for whom it is appropriate to get care while away from the traditional doctor’s office.
Yet we provide telephone care in much the same way and for the same patients we would be doing video care, and there are fewer restrictions on that.
Saving a Trip to the Office
Another example is our anticoagulation clinic, run by several of our nurse practitioners, which manage the high-risk care of complex patients with a broad array of diseases requiring anticoagulation, including deep vein thromboses, pulmonary emboli, atrial fibrillation, and mechanical heart valves.
With the use of home INR monitoring, we are now able to manage many of these patients at home, allowing them to do home monitoring with a point-of-care INR testing machine they keep in the house, saving them a long trip into the office to see us.
Sometimes, the last thing in the world you want, if you can help it, is to make a frail, elderly, unstable patient come via two subways and a bus to get to the office while they’re on Coumadin — risking a fall, head trauma, and a subdural hematoma.
But, try as we might, we’ve been unable to figure out how to appropriately bill for these visits.
There are new codes for this from the Centers for Medicare & Medicaid Services. One is 93793, “Anticoagulant management for a patient taking warfarin, must include review of interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed.”
We have been told that only face-to-face care can be reimbursed — this despite the fact that there are these codes for home management of anticoagulation. To try and use them invites trouble that we just don’t want.
While change is never easy, we can only hope that these larger groups, those who oversee the healthcare industry, who clearly also have a vested interest in making our system better, can come together to ease restrictions and regulations, and to make it easier for us to try new things, to innovate, and to push the envelope.
To take that flight towards better healthcare.