With coverage and access being thrown into question–again–by the incoming administration, it is important to not lose sight of the essentials of continuing healthcare’s 21st century migration. There are a lot of details that get magnified by competing interests, but which miss the big picture of how healthcare is evolving, and must continue to evolve irrespective of political passions.
Healthcare’s future is embodied by three key dynamics: the rise of nurse specialist, the retreat of physicians from specialties, and the portability of EHRs, with respect to both patients and providers. The macro trends in these three areas will be our best bellwether for both remaining focused against the bluster of political transitions, and tracking the long-term evolution of American healthcare.
More Nurse Specialists
Nurses have always had a major caregiving role to play, but the entire healthcare system is shifting to rely on nursing professionals in a new way. There are several movements contributing to the need for nurses to enter roles of greater advanced practice autonomy, responsibility, and especially leadership.
First, nurses can help close coverage gaps. This was written into elements of the Affordable Care Act, and it is an apolitical reality especially in critical access hospitals and community clinics whose mission is to extend access to basic care to vulnerable populations. Clinical nurse leaders represent the new, modern context of nursing as a blend of hands-on caregiving and clinical leadership that can benefit and improve all types of facilities.
Coverage gaps of a different sort are created and exacerbated by changing demographics; broadly, the aging of Baby Boomers. Older Americans, living longer and managing multiple chronic conditions, are a new dominant trend, and meeting their needs without wasting resources is a balancing act. Nurses who specialize in adult gerontology in particular can help keep elderly patients out of hospitals and emergency departments, coordinate care in aging communities and elder care clinics, and generally fill an unprecedented demand for age-specific care.
With the industry-wide shift to focus on preventive services and outcomes-based assessment, nurses again are key to filtering patients more effectively through basic primary care, referral to physician specialists, or providing self-care education and similar resources.
Perhaps most importantly of all, they can do this all faster and cheaper, which is a pain point for all parties, be they patients, payers, or health systems. Nursing education can be completed more quickly than medical school, and advanced nursing students are more able to perform clinical tasks while attaining greater specialized credentials than ever before.
Fewer Physician Specialists
We don’t have an excess of physicians, but we do have a shortage of primary care practitioners. America’s ratio of generalists to specialists is virtually inverted compared to the rest of the developed world. That means even with a high number of physicians, we can still struggle to match every patient with a doctor, or even equip every care team or clinic with a primary care physician.
To an extent, this gap is being filled by the so-called “mid level” providers like PAs, MAs, and especially nurses of various classes, who are collectively providing more patients access to basic care and preventive services. However, we need more MDs staying in general/family practice, rather than going into more lucrative specialties. At the same time that nurses and other non-physician professionals define their new roles in caregiving, physicians are grappling with what this could mean for the relative prestige, compensation, and scope of practice for their domain.
Changing the balance of generalists to specialists is complex, because part of the allure of specialties is better pay and the promise of faster student loan repayment. It isn’t that doctors have failed us so much as that we have failed our doctors: the high-stress, high upfront cost of medical school creates insurmountable pressure on young doctors to treat their calling as a revenue-generator; early retirement, burnout, and suicide threaten physicians of every age, specialty, and experience level.
Again, the makeup of America’s physicians is not something a single administration or policy program is likely to shape overnight; we got here through a long, slow cultural shift. How doctors choose to practice medicine can tilt the scales on basic access, the development of nursing and mid level provider roles, and the country’s collective approach to healthcare.
Digital records systems are the sine qua non for any bright health industry future. However the scales of primary care tip–more NPs, more MDs–they need their EHRs to start delivering in a big way. Effectively turning primary care into the premier touchpoint for chronic condition management, population health, patient engagement, and cost control requires the records and the data to flow, for user experience to appeal and accommodate, and for patients–critically–to have both more access and more accountability.
So far, EHR development has not been particularly responsive, and the role of patients in managing, owning, or even altering their records has been nominal-to-nonexistent. Making our new technology work for all stakeholders begins when it is viewed as a shared tool among all stakeholders. Ultimately, EHRs are a new way to do an old task: communicate. As a communication tool, it must pass seamlessly between payers, providers, patients, and any other stakeholders these three loop in. This is not particularly new insight, of course, but until the cultural norm stops seeing health information technology as a novel obstacle, and starts treating it is a necessary and helpful resource, it will continue to be siloed by admins and caregivers alike, with patients out of the conversation entirely.
The future of the very relationships at the core of healthcare are at stake in how EHRs develop. Getting everyone at the table requires getting the relevant data to everyone.
This is the three-legged stool of 21st century healthcare in America: nurse specialists, physician generalists, and EHRs. Keeping it upright necessarily means balancing these three. Whatever else may come in the form of new leadership or novel technology will have to fit into the paradigm where our next generations of clinical leaders work.