"What the Buck?" Award goes to ...

What the Buck? Award goes to the term “Medicolegal” and to Dr. Wes for propagating the term and all the barriers to innovation and patient-centred care that it represents. 

What the Buck? Award is bestowed upon hierarchical symbols that dominate healthcare despite having lost their crucial relevance in this new paradigm.   These symbols require thoughtful re-consideration of their place in the future of healthcare. 

Medicolegal, yes it is a word according to Merriam-Webster  (circa 1835) that means ‘of or relating to medicine and law’.  There is even a Medico-legal Association in Toronto where doctors and lawyers gather to discuss … oh, I get a headache just thinking about it. 

This week, in his blog When Patients Can Obtain Their Own EKG, Dr. Wes pondered the impacts of the AliveCor EKG case now that the FDA has licensed it as a medical device.  His comments perfectly illustrate what happens when innovation reaches implementation in an inefficient system like healthcare (read more on this issue Which way should healthcare Lean?).

The AliveCor EKG device and app allows patients to record, display, store, and transfer single-channel electrocardiogram (ECG) rhythms from their iphone.  The device has been making news for over a year.  Dr. Daniel Kraft participated in a clinical trial of the AliveCor EKG case and tweeted his EKG back in September 2011. The AliveCor EKG case was touted as one of the Big Tech Health Ideas that will change medicine in 2012 and the device made waves at this year’s Consumer Electronic Show as one of many devices contributing to the emerging quantified self-movement,

Dr. Wes and the term “medicolegal” are bestowed this award because of the importance that a respected healthcare professional put on the medicolegal implications above any other aspects of the device.  Devices should first be considered for their ability to improve health outcomes and increase efficiencies in the system.  If they don’t do one or the other, then their relevance should be questioned but Dr. Wes wasn’t questioning either, he was concerned about how the device will impact him as a cardiologist, “we are entering into new, uncharted medicolegal territory”.  Yes, Dr. Wes, you are no longer in Kansas, it’s a brave new world.  Specifically, Dr. Wes is concerned about; what are his responsibilities to the patient once he prescribes the device; does the device obligate him to be available around the clock to his patient; how will the EKG record be stored in his file; and what are the legal risks?  These probing questions could keep the medicolegal experts busy for years.

I’m not discounting his concerns or his authority to ask these important questions, healthcare administrations, governments and governing bodies should be asking these questions.  However, the discussion should not be isolated from the benefits that these devices may bring to both healthcare consumers and healthcare systems.  Not once did Dr. Wes identify what benefits the device could provide his patients despite acknowledging in his blog that his office provided a demonstration of the device and that he facilitated the prescription for the device for a patient.  If I was his patient, I would assume that if he is demonstrating and prescribing a device, he sees some benefits. 

By the end of his blog, I was left with an unpleasant taste in my mouth.  I sensed that the issue for him wasn’t whether or not the device provided benefits to his patients, but what his compensation should be for prescribing the device and for any impact the device might have on ‘workflow’.   He notes, “There are only so many hours of the day and since I must value that time, cannot bill for this EKG-reading service, and have no quality control over the caliber of the recordings submitted, I consider my interpretations of tracings sent to me to be provided to the patient as a "good Samaritan" in every legal sense of the term.” 

This is a familiar, well-trodden path that the medicolegals have carved out.  In due course, doctors will have quantified the value of their time for both prescribing and monitoring the device and their governing bodies will have negotiated a fee schedule for workflow associated with it.  The lawyers will wrestle with a risk analysis and measure the odds of litigation associated with the device and develop iron-clad terms and conditions, waivers and disclaimers.  When all that red tape is complete, we will see a surge in utilization of the AliveCor EKG device because doctors will be paid to work with it and patients will be asked to assume all the risk.   

This is what happens when medicolegal processes take over innovation.  Thanks Dr. Wes for the heads up. 

If you know a worthy recipient of the What the Buck? Award, send an email to the Fainting Goat at yourfaintinggoat@gmail.com