In this episode of Healthcare Americana, Christopher Habig engages in a thought-provoking conversation with Dr. Anthony DiGiorgio, an Assistant Professor of Neurological Surgery at the University of California, San Francisco, and a Senior Affiliated Scholar with the Mercatus Center.

Together, they delve into the intricate world of Electronic Health Records (EHRs) and their impact on healthcare. Dr. DiGiorgio acknowledges the benefits EHRs have brought, such as improved access to lab results and imaging, but also sheds light on their challenges, including the time-consuming nature of order entry and documentation. The regulatory burden on physicians for EHR usage and the potential role of AI in streamlining these processes are explored.

Additionally, the pair discuss the influence of regulations on healthcare, the concept of free-market principles in medicine, and the need for physician ownership of hospitals. The episode concludes with a powerful message emphasizing that a free-market approach can restore the patient-physician relationship and empower patients to control their healthcare financing, ultimately improving the quality of care.

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[INTRODUCTION]

[EPISODE]

Today's episode, we are going to dive back into really the definition of what it means to provide quality health care. We're talking EMRs, we're talking quality metrics, we're talking, do these things actually help in care settings? Or are these burdens to patient care and the doctor-patient relationship? How we navigate them, and pretty much touching anything and everything under that umbrella. Please welcome to our show, Dr. Anthony DiGiorgio, Assistant Professor of neurological surgery at University of California, San Francisco, and a senior affiliated scholar with Mercatus Center. Dr. DiGiorgio, thanks for coming on to Healthcare Americana. Thanks for joining us.

Some patients may look at extending their life as quality, some patients may just want different functional capacity in their life, and that's their definition of quality. Some patients may want a handful of medications, and to be shown the door, and that's their definition of quality. So it really differs depending on who you ask. Measuring quality is not a bad thing, right? I think any industry in America measures quality, right? Any firm in any industry in America is going to have their own quality metrics that arise naturally within that firm. Every industry, every firm has internal metrics they track. It would be insane for any firm to not track quality metrics. Our division at UCSF, of course, we track quality metrics. These are metrics that come up within the division that we decide are valuable to us as neurosurgeons, that we want to look at going forward.

The problem with the quality movement is when it was associated with the value-based payment movement, where Medicare decided it's going to define what quality is from a top-down approach. And then withhold or give bonuses on payments based on physicians and hospitals meeting these somewhat arbitrary quality metrics. And so I think that's really where the quality movement has started to frustrate physicians, is that these metrics don't always necessarily aligned with what physicians think are important quality Indicators. There's numerous examples. I'm happy to get into, and we go over some of them in our piece in JAMA, that I had the honor of publishing with AMA president, Jesse Ehrenfeld, and one of the affiliate scholars at AEI, Dr. Brian Miller.

Now, you're a big proponent of saying, look, we can actually drive positive change through maybe not CMS, but to state Medicaid programs. Give us a little glimpse on your thinking when it comes to that topic.

So Medicaid, I've been a physician at safety net hospitals basically my entire career. So I have a lot of interest in how Medicaid functions. Medicaid is really great because like I said, it has that sort of experimental nature where different states can try different things, since each state is in charge of its own Medicaid program with some leeway. And then using the free market within Medicaid, and things like Medicaid managed care organizations really allows these interventions to sort of percolate up from the bottom to arise naturally, and not be just these heavy-handed CMS mandates that come from federal government.

I think the overall goal should be fewer people on Medicaid. I think a safety net program is essential. I do believe that that we can strive for universal coverage, given free market principles using Medicaid as a broad safety net. But the key is to make sure that the people on Medicaid are the ones who actually need Medicaid, and not people who might actually be better served on a private insurance plan. Either they're healthy enough, they could get a lower premium. You know, efficiencies can be certainly improved in the ACA marketplaces, where these people could probably get pretty affordable care on a private insurance plan. Therefore, just leaving Medicaid for the people who really do need this social safety net that can't otherwise get a reliable health insurance coverage via the free market.

So, again, if you're a young, healthy individual, you can probably get fairly reasonable private insurance with not a whole lot of government subsidy behind that. That could actually free up Medicaid for those who truly do need it.

And yeah, there are challenges that come with treating Medicaid patients. And that's why we need the social safety net to be there for the homeless person with substance abuse problems, who can't get employer-based health care, and who can't even really manage a health savings account. That safety net needs to be there for that individual because they're going to get care regardless. But at the same time, we can provide better options for that hard working individual who is kind of bouncing between jobs and can't get reliable access to employer based health insurance.

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Once again, we are talking with Dr. Anthony DiGiorgio, Assistant Professor of neurological surgery at University of California, San Francisco, and senior affiliated scholar with Mercatus Center. So obviously, big proponent of the free market, you've done all kinds of studies, you've helped consult on legislative initial efforts at the state level, at the federal level. I'm curious when you're working with the state out in California, and then working with federal, we covered a lot in the first part of this episode of, well, these things need to fall into place in order to do this type of stuff. What is the lowest hanging fruit out of any of the projects you've worked on that you're like, "This wouldn't be that big of an effort to accomplish"?

However, the tradeoff has been very onerous in terms of order entry, of documentation, and the expectation that physicians are always available to be on their EMR. It's almost because the EMR is too accessible. We're expected to always be able to access it. So we ran a study here at UCSF in the neurosurgery department, where we looked at our on call residents, and we pulled their audit logs. We could see from the EHR, how long how long they were actually logged into the EHR, on an overnight 24-hour shift. In a 24-hour shift, they spent 20 hours logged into the EHR. It's clearly a tradeoff inefficiency, because they weren't spending 20 hours gathering, imaging and lab results prior to the implementation of EHR. So where is this that these massive inefficiencies have come with what really should be a time saving technology, right?

If you, again, went back 20 years and said, "Hey, we're going to digitize charts." Every physician would say, "Great, this is going to save so much time." So why is that not panned out? And there's a lot of pain points that we're able to identify in some of our studies that are really kind of tethering our physicians to the EHR.

So all these little things just add up, and it's really death by 10,000 clicks. And then there's regulations on top of that. So if Congress has another, or CMS has another regulation called appropriate use criteria, anytime you order imaging, you have to justify to the EHR why you're ordering that imaging, and of course, it questions you. So I will see a patient clinic, I'll write my notes, I'll say, "Patient has brain tumor, we need to monitor every six months with new MRI." I will then put in the 57 clicks and keystrokes toward the MRI, and then a pop up shows up and says, "Are you sure you need this MRI? Are you sure that's the right imaging modality?" And then I have to click through and say, "Well, yes, this patient has a brain tumor? Yes, I need this imaging." It says, "Well, did you try a CT scan first?" And of course, I had tried a CT scan first, it's in the chart, but I still had to put that through in –

All these things added up, and when we pulled our audit logs from the residence, yes, it's two minutes here with this one thing, and it's another two minutes here, and it's another three minutes here. All these different little regulations that all add up and all of a sudden, you're spending 20 hours on a 24-hour shift logged into the EHR.

But then, again, I'm fearful that it will just be another pop up that will say, questioning my clinical intuition. So I think there's a lot of different ways this can go with it from a regulatory standpoint, to make sure it goes down one of those two paths.

However, I think the regulatory processes are in place for AI to deeper than the physician. So if I am the one that's ultimately making the decision, AI can make my path to that decision easier. Again, you're going back to the example of the brain tumor patient. If I write my note, this patient has a brain tumor, AI should know what I normally do for this patient. AI should be able to read my note and be able to read that patient's past history, and it should go ahead and place that order for me. It should code my note and provide the billing for that note as well. And then it should be able to summarize their clinical brain tumor history for their primary care provider, for their oncologist. So that that person then doesn't have to go through and click through 300 prior notes looking for that little piece of information.

So that's where AI really could be revolutionary. And I think the regulatory framework is actually in place for that to happen now, because it's not actually providing any diagnoses or treatment recommendations. It's simply summarizing, and processing information to make it more efficient.

Dr. DiGiorgio, you already kind of explained a little bit on what your perfect healthcare system looks like, so I'm not going to end with that question. I'm going to give you the famous billboard question. So you are made billboard czar of the United States, you got it controlled. What any message you want to, it's got to be the same one, and it's got to be legible from 80 miles an hour on the highway, you got every billboard in the country to help educate people about this topic and other things you're passionate about in healthcare. What do you put on there?

[OUTRO]

[END]