Where is the Healthcare Workforce ATM?

One of the biggest and most visible workforce transformations in the US and global economies has been the change in staffing patterns for commercial banks. Two decades ago we were just at the end of a generation where legions of tellers provided the entire set of consumer interfaces to services offered by banks. Today, even for those of us who lived through this era, it is hard to imagine having to wait in lines for service or not having worldwide instantaneous access to our cash in the coin of the realm we are visiting. Along the way we have accepted as our responsibility as customer much of the work which was previously done by the bank's employees. As information technology has become more sophisticated and banking has moved on-line the service has become more sophisticated. Along the way the commercial banking workforce has become smaller, more efficient and better skilled.

Labor costs comprise over 60% of the health care bill, and we have lived with the reality over the past forty years that, in any given year, new technology drives more than half of the cost increases in health care. So, health care has lots of labor costs and plenty of new technology, but no overall price savings and little of the impressive consumer cooptation and satisfaction that the banks have managed to pull off. Where are the health care ATMs? The answers are complicated and varied, but worth a look for those who are trying to project out for more than five years for workforce planning.

Now we have two forms of new machines - information technology that has three big domains- managing the administration, improving the clinical, and beginning to expand patient access. It is being applied unevenly across the various domains and has some but not a very robust connection across the three dimensions. Only in a few hospitals does the use of an integrated record for charting a patient's progress inform the process for ordering supplies, projecting staffing needs or other administrative functions. But my bank monitors my transactions and automatically orders new checks when it knows I am out. In no hospital that I have found does the record keep patients informed and generate individualized discharge plans with education for the patient and care giver. But a new piece of software I recently purchased provided me with an on-line assessment in its use and access to the appropriate level of tutorial to improve my skills. So there is work to do here before we see all of the gains from the IT side of the house.

On the biomedical technology side of the house we have a tremendous amount of innovation ranging from the biotech industry and biologics to the increasingly sophisticated imaging and surgical technology. But most of this technology, if not all of it, remains locked up in the hands of expensive practitioners, hosted at institutions that also have a tremendously high cost basis. There simply is no incentive from the manufacturer or the purchaser to compete on the basis of cost. It is all very good, but it is also very, very expensive and shows little promise of changing.

The next generation of health information and biomedical technologies may make a bigger impact as they merge to create a new care management technology. As it becomes possible to monitor patients in a continuous, real time manner, their data could be subjected to management algorithms that access biomedical interventions. This would have a remarkable impact on the way work is done in both the inpatient and outpatient settings, making contributions to both acute and chronic care. Such technologies would more effectively focus professional interest across the various disciplines. Especially if we ensure that as these systems are built they are wired with values and perspectives from medicine, nursing, pharmacy, patients and families. Such integrated technologies would also allow for team work to be shared differently among the professions and with patients and families that will find it easier to stay involved with the care delivery processes. It will also allow for immediate assessment of what mix of inputs produce a better set of outcomes. Will increasing nursing education time with patients provide for faster recovery and fewer readmissions? Does the clinical pharmacist have a bigger impact working with physician, nurse or patient? Now we have experiments of this nature, but they are too diffuse and do not impact the system in a fast enough manner to bring about the level of change needed.

As we think about these technologies and their implications for the workforce, there are several critical questions:

  1. How will each development and innovation enable the outcomes we desire and bring a rationalized focus to the use of resources, especially professional time?
  2. How will each new technology assist us in the macro transition of a system almost exclusively focused on acute care services to one focused on prevention and management of chronic disease and disability?
  3. How will a new technology help overcome cultural boundaries to access, but also provide care that accounts for cultural values and preferences?
  4. How will an innovation bring a faster ambulation of service out of the tertiary care center, clinic or physician office and into the hands of the community, family and individual patient?
  5. How will a new technology make a service more accessible to the global workforce either by shipping the work out or by shipping the patient to a more affordable provider?
  6. How will an innovation enhance the quality of the end user experience because it is more convenient, provides more control, is less expensive or is just novel?
  7. How will a technology allow what we think of as health care to blend more seamlessly with other life pursuits such as recreation, education, and travel?

The technology associated with health care will eventually produce the equivalent of the ATM, but to get there it will have to move beyond just enhancing what is to driving what could be. If banking had used technology as health care does, they would have us still lining up to speak with the teller who would enter our desires into the machine. We need to imagine the world differently.