The Smart Cogs of Health Care

Health care is at a cross roads.  Are physicians the problem or the solution?  I’m not sure how much of the problem they are, but I’m certain they are part of the solution.  Physician behavior is the result of the system within which they work.

Truthfully physicians are the “smart cogs” of health care.  And we need to design a system that optimally leverages this strength.  Deming referred to those front line workers who most understand the processes as the smart cogs.   In health care smart cogs serve two purposes: 1) applying, adjusting and adapting standard processes to individual patients, and 2) leading the creation and continuous improvement of those standard processes.

However, our system of health care hasn’t empowered or enabled physicians to be effective smart cogs.   First, the fee for service model has driven the idea that every thing must be related to the generation of RVUs.  Thus, physicians don’t have the time to do job #2 of the smart cog, and they spend less time doing job #1 simply because it takes time.  Second, the capacity for physician to understand the processes of care is decreasing.  With increasing complexity, even the smartest physicians are finding it hard to be experts in care delivery.  Third, applying the science of quality improvement generates data, and that data needs to be analyzed, which takes time as well as expert knowledge of the science of improvement.  Physicians lack the time and often the skills.   Fourth, medical science knowledge and evidence is expanding at a pace the individual isn’t capable of processing, especially the busy clinician.

So, what to do?  Consolidate, collaborate and commit.  Consolidate into integrated networks where scale can allow for physicians to organize in such a way to allow for proactive process and pathway development and maintaining.  Collaborate across disciplines, departments and care settings to create more patient-centered, effective, efficient and coordinated care processes and clinical pathways that breakdown traditional provider and setting-centric boundaries.  Commit to a new way of managing care and changing the current system with its poorly aligned incentives and poorly coordinated components.

John Haughom, MD, wrote a blog that discusses this issue as well (  He mentions two organizations who have figured out how to empower and enable the smart cogs (Intermountain Health and Virginia Mason).   Dr. Haughom also mentions the importance of having the will to change despite the barriers we face.  Many physicians want to see change, yet they aren’t driving change.  Many managers of health care systems want to see change, yet they can’t make it happen fast enough.  We seem to be caught in the hamster wheel of the current system.  We need to figure out how to allow enough breaks from the current wheel to improve the efficiency of the system, so that more resource and time can be freed up to allow for more proactive process improvement.