“Healthcare Whac-a-Mole”.  This word combination seems incongruous. Like Batman and Roast Beef.  Hansel and Gatsby. Carpe Goldfish. But in this blog, I will explain how Healthcare Whac-a-Mole is a perfect analogy for how we try (and fail) to solve problems in healthcare. Additionally, it will serve as a paradigm for how to fix healthcare – the right way.

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For the 0.037% of you who have never played Whac-a-Mole, it’s an arcade game created in 1975, where cute plastic moles randomly pop out of their holes. The game’s objective is as follows: when a mole pops out its head, you smack it down using a soft mallet shaped like Thor’s hammer.  In doing so, another mole (or 2) will randomly pop up elsewhere, whereupon you endeavor to smack that one down too, and then another mole pops up, and so on.  The entire game is based on hitting something down which causes something else to pop up elsewhere. You get it.

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To understand how this relates to healthcare, we must first level set on 2 concepts: systems of care, and traditional healthcare problem-solving methodology.

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Systems of Care

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Definition: A system is defined as a set of elements that work together to achieve a common goal. Think of a healthcare system as one in which there are many steps that need to occur flawlessly for the desired outcome to be achieved. For example, an incidental pulmonary nodule is discovered for which the desired outcome is a diagnostic bronchoscopy.  

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Behavior: Systems are complex and inherently unruly. A small change in one part of a system leads to a large and unpredictable consequence in some other part of that system. Change one thing, something else gets worse.  Kinda sounds like Whac-a-Mole!

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Traditional Healthcare Problem Solving – the Wrong Way

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We try to solve problems in healthcare by committee.  Let’s say our system of care is not functioning well.  Mistakes are being made, things are missed, and outcomes are suboptimal. Assuming we recognize that there IS a problem (that’s a whole different blog), we assemble a committee of well-meaning smart leaders in a room who decide the solution…

• without actually understanding the real problem
• often with inadequate data
• commonly without measuring the effect on the entire system they are perturbing
• and ignoring the very real possibility that changing one part of a complex system can lead to unpredicted and sometimes disastrous outcomes in some other part of the system.  

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They put in 4 quarters, push the start button, and Healthcare Whac-a-Mole begins.

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An Example of Healthcare Whac-a-Mole 

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Because of the failure of the US healthcare system to reliably follow through with abnormal test results, the government decided that all results be immediately released to patients through their electronic health record (EHR) portal (the 21^st Century Cures Act). The (committee) reasoning behind this act was as follows. If patients knew about their abnormal results, it would increase the likelihood that they would follow through with any necessary next steps. They emphatically smashed that poor little mole on its head.

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However, let’s explore this a bit further. All test results. Normal and Abnormal. Regardless of whether an action was needed or not. Immediately. Before their provider could reach out to them. So here are 2 other moles that popped up.

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• The “It’s OK but I don’t know that” mole:
  • I’m a rheumatologist.  All of my patient’s results are “abnormal”! But precious few actually need anything done. Either their condition or my treatment has resulted in a value that falls outside the range of the average healthy person but is perfectly medically acceptable and expected. So when a patient gets a result with a little yellow flag next to it, or medical jargon that is confusing, they may choose to contact their provider’s office for an explanation – something they would not have done in the old system. More work. Lots more work.  In fact, a study by Steitz (1) suggested that the volume of daily messages sent by patients almost doubled after the Cures Act.  
  • So releasing results immediately (whack mole 1) had the unintended consequence of significantly increasing provider work (up pops mole 2). And we know that excessive EHR work leads to provider burnout (up pops mole 3) resulting in fewer providers (up pops mole 4) so more things are missed (up pops mole 5). A significant change to a complex system can result in unintended consequences that ultimately make the problem worse, not better.

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• The “It’s Cancer and I’m Going to Die” Mole:
  • In this example, a markedly abnormal test result, written in medical jargon that patients are unlikely to understand, informs them through the coldest mechanism possible – an EHR text message – that they have something that might/could/will kill them now/soon/later. A terrible anxiety-provoking experience causing many other moles to pop up. And, in this author’s personal opinion, it’s a horrific way to communicate to your patient that they have a serious and potentially fatal illness. Especially when the result is unanticipated. It’s not that the patient shouldn’t be informed, it’s how best to inform them. And it always seems these terrible unanticipated results are released on a Friday night.

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Healthcare Problem Solving – the Right Way

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So how do we fix things?  You can’t redesign a failed system, you have to design a new system. Let’s go back to our game of Whac-a-Mole and assume that every mole that pops up is a failure in the system. Our goal then isn’t to keep hitting these poor moles on their noggins’ but rather to stop them from popping up to begin with. We need to create a solution that covers all of the holes. A new system in which no moles pop up, and no moles need to be whacked.

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Let’s focus on the example I gave in the beginning – the incidental finding system of care. An incidental finding is discovered, and an action needs to be reliably completed. In this system, there are at least 10 critical human steps, all of which need to happen flawlessly, for the right thing to happen. As we have just stated, solutions that only deal with part of this system, that only whack one mole, can make things considerably worse.

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The bad news is that many health systems address this issue by whacking a single mole – using companies that have a product that does one thing in this system – or whacking a few moles by bastardizing existing EHR functions in ways they were not designed (or tested for). And even worse, these mole-level adjustments are often put into place without truly measuring the effect on the other parts of the system.

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Fortunately, there is a solution out there, from a company that gets it. In my previous job as Director of Clinical Innovations at Geisinger, I developed a new system of care for the management of pulmonary nodules. I was looking for an IT solution that would support this entirely new system of care, and I found it with Eon. Their IT solution for incidental findings is comprehensive and touches on all steps (all moles) involved in the identification, care plan setting, tracking, and reporting of incidental findings. Go wide. But they also cover virtually all body systems affected by incidental findings. Go deep.

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Putting This All Together

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We now know that trying to fix a broken system of care by only addressing one piece of the system is the wrong approach. The best solution replaces the failed system with a new system of care, using people, processes, and information technology – efficiently, effectively, and in a patient-centered manner.

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The only Whac-a-Mole we should be playing is in the arcade.

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References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8524306/

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