More outreach doesn't find the patients nobody is counting

I forgot the number of times I sat in rooms with care operations leaders and nodded along at the capacity argument. Someone would say “we’re hiring more coordinators,” and I would say “yes, exactly,” in the warm serious voice you use when you would like to be invited back. I kept notes. If you email me for them, I’m going to reply with a picture of a Roomba.

So here is the thing I should have been saying:

More capacity does not find the patients nobody is counting. Hiring the fifth coordinator, buying the call center, pointing an AI voice agent at the list: all of that works the list. The list is not the problem. The problem is who isn’t on it.

Part 1: We are all The Count

There’s a purple vampire on Sesame Street called The Count, who… counts things. “One bat! Two! Three bats! Ah ah ah.” He has been doing this since 1972 and he has never once counted the bats that didn’t show up. He can’t. The bats never left the cave. They cannot be counted by a guy whose entire methodology is looking at what’s in front of him.

That’s your EHR. I know you paid a lot for it. A magnificent and extremely expensive record of things that happened. If nothing happened, nothing got written down, and if nothing got written down there is no row, and if there’s no row there’s no patient, and if there’s no patient, congratulations, you have zero problems, you can go home. No one in healthcare can just go home as the work is never done.

Patel and colleagues, Journal of General Internal Medicine, 2018: of 103,737 primary care referrals, 35% ended in a documented completed visit. Thirty-five. And that’s documented. Some of the other 65% is a visit that happened and never made it back into the record. Some of it is a person who never showed up. From inside the system you cannot tell those two apart. That deserves its own post for another day.

Part 2: The capacity math, which does not work

You hire a coordinator. The coordinator gets a worklist. The worklist is generated from the record. So your new hire spends her week calling people who already came in, which, fine, I’m not anti-phone. But the patient referred to cardiology in March who never went, whose cardiology practice never knew he was coming because the fax went somewhere: he is not behind in a queue. He is not in a queue. Adding a second coordinator gives you two people not calling this exact patient.

This is what I see happen in reality. The worklist is generated from the thing it’s supposed to be checking. You query the record for who needs follow-up, you work that queue to zero, the execs are delighted. Then someone builds a report to validate the queue, and that report also sources from the record, so it also agrees, and now two systems agree with each other about a population neither of them can see fully. This continues until you get a list from somewhere else entirely - generally a payer sending you all the gaps in care in your population - and you find out too late what you’ve been missing.

If your data warehouse already handles this, go in peace. Just pull the referrals your organization sent in March, the ones that didn’t come back, and tell me whether that query returns a number or returns a meeting. Spoiler alert: It returns a meeting. Someone says “well, it depends what you mean by completed,” and then it’s Thursday.

Part 3: Nobody signs for the thing that didn’t happen

My favorite description of all this comes from a medical director at a correctional health provider, tracking off-site referrals for a population that cannot exactly drive themselves to the appointment. He said: “Imagine the biggest spreadsheet you can imagine that is interconnected with other spreadsheets.”

That is a coping mechanism, coming from a sharp operator. When your best people all reinvent the same enormous cursed spreadsheet, the software didn’t fail them. It declined to solve the problem.

In medicine, accountability attaches to a licensed human performing a discrete, signed act. That machinery has exactly one hole in it: what didn’t happen has no signature. When nothing happened and something should have, there is no act, no actor and no row in the worklist. You cannot sign for an absence.

Care orchestration should bring you what the record doesn’t: the denominator, who should have been seen and not just who came in, and current state computable at any point in time: what is true now, what’s due next. Not the state when someone last documented it.

Capacity is a real lever. I’m not telling you to fire anybody. I’m telling you that you can pull this lever until your arm comes off. The March referrals are still going to be sitting there doing nothing in particular.