Pay-for- Frustration in Small Home Health Agency

Problem: Too Many CMS Rules and Paperwork to Ensure “Quality”

Solution: Have CMS Bureaucrats Serve Time in Home Health Agencies as Part of Job Training

After I wrote a Healthleaders article on Pay-For-Performance possibly not being what it’s cracked up to be (see yesterday’s blog), I received this note.

Dr. Reece:

I applaud your common sense description of the P4P plight we all face. I’m the director for a Home Health agency in Ohio. We face the same problems in the Home Health environment with respect to poor patient compliance based on cultural and financial problems that patient care is frought with.

You were right on with the comment, politically incorrect or not, that "Patients are equally responsible for bad disease outcomes". Is it fair to punish physicians and agencies for poor choices?

And what about the nature of the human condition itself that lends to the inevitable outcome of the body "wearing out"?

And what of the patients who are non-compliant and are given notice by their physicians that they will no longer treat them? We all know the P4P quality measures will be negatively affected by these types of patients.

The same holds true in home health. There is already fear that we will avoid co-morbid patients because of predisposed potential for a downhill spiral prior to discharge from home care.

Chronic conditions such as COPD, diabetes, CHF, diabetic wounds among others are repeat offenders when it comes to re-hospitalization and emergent care.

This can't be helped and so I ask those that will rely on P4P as a payment guide to ask this question: What will become of agencies who care for these patients regardless of P4P percentages?

And what will become patients who are avoided because P4P threatens to remove these monies if the percentages fall below "their" idea of quality?

Ask these patients who depend on home care nurses and aides who help them cope with their medical problems. Not to mention physicians who rely on us as well to manage follow-up and change in treatment regimens so as to prevent emergency room visits.

I recommend that those who make these determinations should walk a mile in ALL our shoes!

Ellen Henderson, RN, Director
Twin City Home Health
Dennison, OH 44621
740-922-7450 Ext. 3901

I followed up by calling Ms. Henderson. She runs a small home health agency – 12 employees with about 40 home health patients. The agency is affiliated with a 25 bed rural hospital.

She says current CMS reporting requirements burden her staff. Federal rules may require 2 to 4 hours of paperwork to meet quality requirements. “That’s time we could better spend caring for patients.” What P4P might add to the red tape, she doesn’t know, but she fears the worse.

Many of her patients are non-compliant. Their behavior poses safety hazards beyond the control of her staff. One client insists on keeping kerosene cans next to his oxygen tank; another suffers a wound infection from a dog licking his wound.

Even though satisfaction surveys show a 99% approval rating among her agency’s home health clients, she notes “We look bad on quality surveys because we accept patients with chronic disease and multiple co-morbidities.”

Other agencies hesitate to accept these patients because they reflect badly on quality ratings, She said home health agencies across the land are resisting mandatory P4P participation “because it would put us out of business.”

She said home health agencies would like to see major changes in regulations that would not punish agencies who care for chronically-ill patients with poor prognoses.

I have a modest proposal: have fledging CMS bureaucrats spend a week in a home health agency filling out CMS forms, going on home calls, and observing how patients comply as part of their job training.

The moral is: Bureaucratic regulations have unforeseen complications: things don’t always look the same from the bottom-up as from the top-down.

Pay for Whose Performance

Buzz, Metrics, Outcomes. and Human Nature

This originally appeared HealthLeaders News, Mar. 16, 2007

As an occasional contrarian, I sometimes question accepted wisdom. One piece of dogma I hear repeatedly is that physicians should be held directly responsible and strictly accountable for patient outcomes and should be paid accordingly. That’s the essence of arguments for pay-for-performance programs.

Below, I raise these three questions:

1. Should physicians be paid extra for performance by “administrative pricing regulators” when physicians are professionally obligated to do the right thing in the first place in the best interests of patients?
2. Will P4P in all its complexities and unforeseen consequences slow growth of healthcare spending?
3. Should P4P programs be extended beyond the hospital to outpatient settings?

Contagious Buzz

Accepted wisdom is contagious. Hang around hospital and health plan executives long enough, and you will hear a lot of buzz about quality.

The buzz goes like this:

• “Quality and metrics are where it’s at.”
• “All we need to do is to get our arms around the metrics.”
• “If only we could get clinicians to behave and follow measurable quality indicators.”
• “Pay for performance is the wave of the future, if only doctors would climb on the bandwagon.”
• “Manage doctors, and you manage quality.”

Metrics conflicts

The buzz on the doctor side of the aisle may differ. Some doctors are openly skeptical about the value of P4P. Why are some doctors dubious about measuring outcomes and being paid for them?

From the doctor standpoint, there may be several reasons, as evidenced by the Winter issue of the Minnesota Quality Review report, which contains a number of provocative articles.1

Here are some of their titles:

• “Paying for Performance: Physicians Support It But Want It Tweaked, Tested, and Watched Closely.”
• “Not Really What the Doctor Ordered.”
• “Is Everything Negotiable: Physicians Find They Often Have Some Leeway to Negotiate Pay-for- Performance Goals with Health Plans.”
• “Pay for Whose Performance? Minnesota Clinics Carve Up the Bonus Pie in Different Ways.”

I take these articles seriously. As former editor of Minnesota Medicine and a lifelong student of healthcare in Minnesota, I know Minnesota physicians, who tend to congregate into large well-managed groups, are scrupulously dedicated to quality.

Serious Questions

Yet Minnesota doctors question whether:

• Quality measurements are for the benefit of hospitals and health plans rather than for doctors and patients. In other words, pay for whose performance? P4P, I find, is not really what most doctors would order to judge their own performance.
• P4P bonuses for doctors, typically in the 3 percent range, are a sufficient incentive to pay for installing expensive electronic health systems to record doctor-entered quality indicators, which are necessary to track outcomes.
• They should have more leeway in negotiating P4P goals with health plans and in setting realistic standards.
• P4P programs are really effective in improving quality and may be at the tipping point.
• Current evidence of P4P justifies them being applied nationally.2,3
• Health plans and hospitals realize patients are often more responsible for disease outcomes than doctors themselves.

Thin Evidence of P4P Effectiveness

Why is the increase in quality and outcomes only marginally effective with P4P programs? After all, it is intuitively compelling that a broad base of evidence aligning outcomes with bonuses would work. However, the evidence is thin indeed that P4P actually works.4,5

What’s going on here? Is it because:

• Doctors aren’t concerned about quality?
• Demands in costs and efforts in money, training, staff time in installing systems and entering and tracking data are excessive?
• Doctors are technophobic?
• Sixty percent of doctors are in practices of four or less and simply lack the IT infrastructure to track P4P?
• Patients fail to change behavior and don’t comply with instructions once out of the reach of doctors and hospitals?

Doctors and Bad Outcomes

Politically and intuitively, it’s easy to blame doctors for bad outcomes. Doctors are the authority figures. Doctors write the prescriptions, treat the patients and control the money flow. You often hear the truism doctors generate or control 80 percent of money expended in the system, although I have yet to meet a doctor who believes this.

It would also seem to make intuitive sense that improving “processes of care” in the outpatient environment would improve outcomes. But this may not be so. The Health Disparities Collaboratives of the Health Resources and Services Administration recently performed a controlled preintervention and postintervention study of 9,658 patients with diabetes, asthma and hypertension participating in community health centers quality improvement program.6

The conclusions? “The Health Disparities Collaborative significantly improve the processes of care for two of the three conditions studied. There was no improvement in the clinical outcomes studied.”

No mention was made of the patient behavioral factor, merely that “the substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods.”

In judging outcomes, it’s much harder to measure noncompliance and unhealthy behavior of patients outside traditional care settings. Besides, patients are supposedly at the mercy of the doctors and are most vulnerable to high health costs.
Can you imagine a health plan or Medicare official saying, “Patients are equally responsible for bad disease outcomes”?

I can’t. That would be politically incorrect, certainly insensitive and maybe even scandalous.

Human Nature and the Declaration of Independence

There are other factors as well–human nature and independent patients with their own minds. As John Naisbitt points out in Mind Set! (Collins, 2007), the U.S has an “overwhelming bottom-up society.” Americans believe in individualism and freedom, and patients tend to behave the way they want to behave and change behavior and old habits only reluctantly.

As an example, 40 percent of type 2 diabetics at risk ignore doctors’ advice to be active. And the more in danger patients are, the less likely they are to be inactive.7

A Smoking Gun

I vividly remember a photograph of John Johnson, a West Virginia coal miner, on the front page of the New York Times (Eckholm, Eric, “Medicaid Prods Patients Towards Health,” December 1, 2006).

Johnson, 61, had lost a leg to diabetes and was smoking a cigarette in the Times photo. When doctors urged him to change his diet and to stop smoking to qualify for better Medicaid benefits, Johnson said, “I told them I eat what I want to eat, and the hell with them. I’ve been smoking for 50 years–why should I stop now?”

Self-evident Truths

Other self-evident truths exist as well. Here are five:

1. People spend 99.9 percent of their time outside of doctors’ offices and hospitals. This time gap is particularly important in patients with chronic disease. Your outcomes depend on how and where you live and work. The system recognizes this. It is decentralizing and moving chronic care management to homes and worksites. Internet and nurse monitoring may help close monitoring disease gaps. But gaps in care--gaps beyond the physician’s control--still loom large. Insurance coverage may or may not be important in outcomes. According to Amy Finkelstein of MIT, Medicare had no effect in reducing elderly mortality in its first 10 years of existence (“The Cost of Coverage: The Sobering Lessons of Medicare,” Wall Street Journal, February 28, 2007.)

2. Many patients don’t follow doctors’ orders. Many never fill prescriptions, fail to get refills and avoid exercise. The lack of prescription compliance has led to a boom in physician office dispensing, the rationale being that patients are more likely to follow instructions when the doctor directly hands them the prescription, looks them in the eye and tells them to follow orders. And it’s no secret that fitness centers are a great business because of the high recidivism rate of subscribers to these centers (more than 50 percent drop out).

3. Many people dig their graves with their own teeth, hence, the obesity epidemic, which has now reached worldwide proportions.8 That’s why obesity is replacing smoking as the poster child for preventing chronic disease, and health plans will be paying members to join Weight Watchers and similar organizations.9

4. Half-way technologies–stents, coronary bypasses, joint replacements, statins, etc.–don’t eliminate underlying diseases or change their basic pathophysiology. The problem here, of course, is many patients have overblown expectations at what these technologies will accomplish and often return to the behavior that led to the problem in the first place.

5. Modern technologies--cars, home computers, video-games, TVs, etc.–confine movement and foster obesity. These technologies are part of the culture and are beyond the physician’s influence. Add to these technologies junk food, transfats, absence of suburban sidewalks, lack to time to exercise, and you compound the outcome problem. To paraphrase James Carville, when it comes to obesity outcomes, “It’s the culture, Stupid!”

Doctors aren’t Blameless

Doctors aren’t blameless for poor outcomes or for failing to follow guidelines. It’s well-documented doctors only follow preventive and treatment guidelines 50 percent to 55 percent of the time. Moreover, doctors could do a much better job communicating with and educating patients, deploying the Internet (for example) to reach patients when they are outside of the immediate care setting.

Doctor-patient education outside the office is beginning to take off. Two examples spring to mind:

1. Emmi Solutions, founded in 2002 by a Chicago urologist, David Sobel. The company provides online interactive programs of what to expect from surgical procedures and chronic disease episodes and gives them to patients and their families to view at their leisure at home.

2. EDocAmerica, founded in 1998, by Charles Smith, a family physician and medical director at the University of Arkansas medical center in Little Rock. His company, staffed by 12 national family physician leaders, uses the Internet and email to “prescribe” healthcare information for employees of large groups about their health care options.

Compelling doctors to follow guidelines and enforcing their compliance is not as easy as it might seem. Whose guidelines? Keep in mind there are more than 2,000 guidelines floating around out there. You may find them at the National Guideline Clearinghouse website (www.guideline.gov). These guidelines depend on both evidence and opinion and are neither infallible nor a substitute for clinical judgment.

Doctors are mortal and may have a hard time keeping all these guidelines in mind. Small wonder that adherence to guidelines and outcomes vary. As I outline above, patient behavior outside of the office and hospital settings is an important factor in healthcare outcomes. Doctors can’t be held solely--or even primarily--responsible for outcomes, and rewarding or punishing them for outcomes may be overly simplistic.

Doing so in the confined hospital setting may make P4P advocates “feel good,” and it is a good place to start, but P4P may not lead to better long-term outcomes.
Quality, outcomes and metrics to measure the relationships among these three are very much the buzz these days, especially in hospital, health plan and Medicare circles. Often the blame for poor outcomes falls on doctors.

What this buzz fails to address adequately is failure of patients to comply with doctors’ instructions and to change unhealthy behavior when out of the doctor’s immediate sphere of influence.

Perhaps Rodney Hayward, M.D., from the VA Ann Arbor Health Services Research and Development Center of Excellence and Schools of Medicine and Health at the University of Michigan, says it best: “The last thing we need is a performance-measurement system that encourages a little improvement in quality and a substantial increase in costs.... The value and importance of most medical treatments vary tremendously among patient populations in complex ways.... Until our performance-measurement system is based on clinically relevant information and targets high-priority care, performance measurement is likely to remain a great idea that is more of a distraction than a benefit.”10

A Few Final Points •

--P4P may be “fundamentally a social experiment likely to have only modest incremental value.”3
• P4P is an experiment worth conducting in hospitals.
• The closed hospital environment is a good place to start because it addresses high priority clinical problems.
• Doctors in hospital practice should follow existing quality indicators.
• P4P in outpatient settings will be hard to implement and is unlikely to improve outcomes.
• Berating physicians for high costs and poor outcomes is a counterproductive strategy.
• Rewarding physicians for what they are professionally obligated to do in the first place may be an unrewarding and counterproductive strategy.
• Resistance to behavior change among patients is significant and makes long-term P4P measurable outcome improvement unlikely.
• Outcomes depend heavily on cultural factors.
• Resources devoted to prevention and wellness are more likely to be effective in improving outcomes than P4P.


References

1. MMA Quality Review: “Physicians in Pursuit of Excellence,” Winter, 2007.
2. Lindenauer, P., Remus, D., Roman, S., Rothberg, M., Benjamin, E., Ma, A., and Bratzler, D., “Public Reporting and Pay for Performance in Hospital Quality Improvement,” New England Journal of Medicine, volume 356, pages, 486-496, 2007.
3. Epstein, A., “Pay for Performance at the Tipping Point,” New England Journal of Medicine, volume 365, pages 515-517, 2007.
4. Rosenthal, M., and Frank, R., “What is the Empirical Basis for Paying for Quality in Health Care,” Med Care Res Rev, 63:135-157, 2006.
5. Peterson, L., Woodard, L., Urech, T., Daw, C., and Sookanan, S., “Does Pay-for-Performance Improve the Quality of Health Care?” Ann Intern Med, 145: 265-272, 2006.
6. Landon, B., Hicks, L., O’Malley, A., Lieu, T., Keegan, T., McNeil, Barbarad, and Guadagnoli, E., “Improving the Management of Chronic Disease at Community Health Centers,” New England Journal of Medicine, volumes 359, pages 921-934, 2007, March 1.
7. Squires, C., “Study: Most Diabetics Don’t Exercise,” Associated Press, January 26, 2007.
8. Hossain, P., Kowr, B., and El Nahas, M., “Obesity and Diabetes in the Developing World,” New England Journal of Medicine, 356:313-315, 2007.
9. Spector, H., “Insurer to Pay for Weight-Loss Efforts,” Cleveland Plain Dealer, February 1, 2007.
10. Haward, R.A., “Performance Measurement in Search of Path,” New England Journal of Medicine, 356:951-954, 2007, March 1.

The Medium is the New Health Care Message

Taking an Hones Visual Look at Health Care

The medium is the message... There is a basic principle that distinguishes a hot medium like radio from a cool one like the telephone, or a hot medium like the movie from a cool one like TV….Hot media are low in participation, and cool media are high in participation or completion by the audience.

Marshall Herbert McLuhan, 1911-1990, Understanding Media, 1964

Mindset #11 – “Don’t forget the ecology of technology.” The changes that result from the technologically driven onslaught of the visual can have profound impacts on the environment in which you operate and the environment of the marketplace that you address. Ask yourself what in those environments will be enhanced, what will be diminished, and what will be replaced because of the changes.

John Naisbitt, Mind Set! Collins, 2007

I have a dear friend, Brian Klepper, PhD, founder the Center of Practical Health Reform and now executive producer of NCI Talk (ncitalk.com), an educational and consulting company specializing in managing health care costs. Brian also has a personal blog , ncitalk.com/wordpress, which I invite you to read.

The Message

Brian’s focused message is that the two major flaws leading to soaring health costs are fee-for-service and lack of transparency. He believes only the business community and major health care sectors have the heft and leverage to correct these flaws. They can do it , he believes, through use of information technology management systems that compare costs, outcomes, performance. and reward the most efficient providers and suppliers.

His message is two fold to his audiences – use your clout to enforce efficiency measures and to achieve quality management. The audiences include those attending the World Health Care Congress, cancer meetings, American College of Surgeons conclaves, the National Association of Health Underwriters, and gatherings of those who represent health care supply chain vendors. I applaud Brian’s message because it relies on employers and business sides of health care to correct the health system’s flaws rather than the government.

On the hospital side, Brian’s message to hospital executives is honest and sobering. It is this.

A) Hospital revenues come mainly from two sources: government programs (Medicare and Medicaid), and managed care organizations serving as intermediaries and surrogates for employers.
B) Hospital costs spring mainly from two sources: labor costs, supply chain costs.
C) Hospitals are losing ground financially. In an aging population with growing numbers of uninsured and an employer market that is either dropping coverage or dumping costs on employees, patient mix is shifting to the government side of the equation, which pays the least, and away from private sources of payment, which pay more.. .
D) Hospitals can’t do anything about the inevitable demographics, and it can’t do much about the shift of consumers away from the hospital to less costly environments. Nor can the hospital do much about rising hospital labor costs, for it needs skilled professionals to remain competitive. But hospitals can do something about its supply chain costs, its most rapidly rising expense and a market in which vendors often have margins exceeding 50%.

NCI Talk Videos

Effectively managing costs is where NCI talk, which might be more aptly called NCI voice views, comes in. Brian regularly tours the country to do video interviews with leading medical visionaries and innovators. Recently, he visited Washington State and Oregon to videotape interviews with multiple health care leaders, both physicians and non-physicians.

Among physician leaders, he interviewed were.

• Gary Kaplan, MD, CEO of Virginia Mason, an integrated health organization in Seattle that has adopted and modified the Toyota lean production model for its own purposes;
• John Kitzhaber, M.D. two time governor of Oregon, who is deep into devising a universal means-tested plan for Oregon that regulates public but not private coverage;
• David Lynch MD, of Bellingham, Washington, who heads up a group of 50 doctors with eight or nine medical offices covering a population of 170,000 and “doing all the right things” to offer safe, effective, and best practice care.

What’s Different about NCI Approach

To me what’s different and innovative about the NCI approach is its talk show approach. This approach consists of integrated videos featuring three expert guests talking on a single topic; a seasoned talk show moderator; a mini-documentary based on one of Brian’s visits and directed towards the audience of interest; and a closing video by Brian summing up the implications of what has been said

Under the rubric of “Taking an honest look at healthcare,” these videos are presented to health care conference audiences on subjects like comprehensive cancer care, proactive pay for performance programs, quality management, greater efficiencies, and rationalizing supply chain costs.

The Medium is the Message

NCI with Brian as its executive video producer is on the right track. To use John Naisbitt’s words, “a visual culture is taking over the world.” In a culture dominated by video games, TV, Internet images, cell phone and Blackberry pictures, and YouTube, this visual approach has profound and broad implications beyond health care. Naisbitt lists eight manifestations of a visually dominated world.

1. The slow death of the newspaper culture
2. Advertising – back to a “picture is worth thousands of words”
3. Upscale design of common goods.
4. Architecture as visual art
5. Fashion, architecture, and art
6. Music, video, and film
7. The changing role of photography
8. the democratization of the American art museum

In health care, visual forms of communication – animation and voice-guided online interactive programs featuring illustrations and simple language- may soon replace or at least supplement powerpoint presentations. Everyday Americans listen to 25 million powerpoint talks, and many, including myself, are growing weary of bullet points. Subconsciously, whether we’re aware of it or not, many of us now may be wearing bullet-point protective vests. Many will welcome straight talk, clear pictures, and moving images to tell the story

Medicare and the VA

Less “Universal”Than Meets the Eye

Yesterday I visited a relative in a “skilled nursing facility,” The facility is a one story sprawling brick structure holding 120 patients. It has four wings, each staffed by four aides and one LPN for each 8 hour shift. Medicare covers most patients. You can stay for 100 days under certain conditions.

Otherwise you pay $9000 a month. I don’t quibble with the expense. Aides, nurses, physical therapists, pharmacists, and doctors work hard caring for mentally or physically disabled, often incontinent patients. Caring for these patients requires expensive equipment – monitoring devices, portable toilets wheel chairs, machines for lifting patients in and out of bed.

My Relative – a 73 Year Old Veteran

My relative is a 73 year old veteran. He receives disability from a back injury incurred while in the service. For the last 20 years, he has received care off and on from the VA. He suffers from Lewy Body disease, a variant of Parkinson’s disease that often ends with dementia. He has been hospitalized six times in the last year with aspiration pneumonia, has insulin-dependent diabetes, and suffers from chronic bronchitis and emphysema. He receives 40 pills daily, can’t walk and talk, and has trouble feeding himself.

Medicare Rules and VA Bureaucracy

Come next week, unless he shows progress, Medicare will force him to leave the nursing facility. His wife can’t afford the $9000 it will take to keep him there.. She has thought of the VA as an alternative. She has called the VA multiple times and listened to its lengthy telephone menu, but has yet to connect with a human voice. She has, she believes, hit a bureaucratic brickwall. She fears there’s no way through it or around it. But the Parkinson’s Foundation assures her, under the right circumstances, the VA will provide home care benefits. I’ve tried to help by googling the VA Office of Geriatrics and Extended Care. It has 250 Frequent Asked Questions, and a comment box where you can seek help.

The Question – What Lies Ahead Politically ?

My admittedly fleeting experience in the skilled nursing facility and the VA raises this question in my mind: What do existing government “universal” programs portend for future “universal coverage?’ I can’t help but reflect on what the present presidential candidates are promising.

On the Democratic side,

• Former senator John Edwards promises universal coverage and would pay for the estimated cost of $90 to $120 billion by raising taxes on the “wealthy.”
• Senator Barack Obama doesn’t have a detailed plan but says he “would create a political consensus around the need to solve the problem.”
• Gov. Bill Richardson would offer tax credits to help buy insurance and extend Medicare to cover those from 55 to 64.
• Senator Hillary Clinton would ”end price gouging, cost-shifting, and unconscionable profiteering..”
• Senator Christopher Dodd would forge a consensus to cover all Americans and raise taxes.

Most Democrats say they would raise taxes on “the rich” to pay for universal care. Other than public resistance, there’s one small nagging problem with raising taxes. As Presidents John F, Kennedy, Ronald Reagan, and the present president George Bush have shown, the surest way to raise government revenues to pay for social programs is to cut taxes. It works every time. Another problem is that existing government programs often produce waiting lists. My relative’s wife says she has been told she will have to wait for 2 years before her husband would qualify for a VA geriatric unit – which will of course be too late.

But let there be no doubt. Democrats “own” the health care issue, which accounts for their confidence in their rhetoric about universal coverage. You see, unlike the Republicans, they have this “plan” called “universal coverage.” Never mind the details about extraordinary costs of such programs (the Johnson administration said in 1965 Medicare would never exceed $9 billion, today it costs over $250 billion), the miserable service record , the inevitable waiting lists, the archaic VA facilities, and the endless impregnable bureaucracies. Besides, Democrats know universal coverage “polls fabulously” – who doesn’t want “free’ government coverage financed by the “rich?”

The Republicans? Well, the public doesn’t trust them on health care. Americans –frenetic, fearful, and furious -- over spiraling health costs, simply will not listen to complicated arguments about incremental change, or constant innovations, no matter how good these changes or innovations promise to be. Governors Arnold Schwartzenegger and Milt Romney have swaggered forth with “universal-lite” state plans heavy on regulation and taxes, targeted on health plans and providers, and payroll taxes. Polls favor these initiatives.

Troubles on the Horizon for State’s Universal Coverage

There are trouble signs on the horizon for these state plans. Health care and small business lobbies vigorously oppose being the “fall guys” for politically ambitious governors. State plans are already projected to cost much more than originally planned.

In Massachusetts, government spending will be $276 million rather than the $151 million promised. And premiums for uninsured workers will be $380 per month rather than the promised $200, amounting to as much as 6% of their income.

In California, the plan will cost $12 billion, in addition to the taxes on hospitals, doctors, and small businesses.

The biggest problem for Republicans is that they have no clear comprehensive Grand Plan for alleviating the cost and coverage crisis. Dr. Tom Coburn ( R.), the senator from Oklahoma, is said to have a bold plan, based on fundamental, bottom-up reforms cast in the language of markets, consumers in control, revamped tax codes favoring individuals, and health savings accounts, but his plan has yet to reach the level of widespread public consciousness.

A Sad Ending

Sadly, none of these future “universal plans,” as put forth by either political party, or the existing “universal coverage” systems of Medicare or the VA, will help my relative – or his wife -- pay for his end of life illness. Given his helpless condition, and his wife's inability to care for him there, he won’t be going home again. Where he goes, no one knows - and no one knows who pays.


References

1, Pear, Robert, Candidates Outline Ideas for Universal Health Care, New York Times, March 25, 2007.
2. Bellick, Pam, Massachusetts Sets Benefits in Universal Health Care Plans, New York Times, March 21. 2007/
3. Pipes, Sally, Intensive Care for RomneyCare, Wall Street Journal, February 26, 2007
4. Strassel, Kimberly, Republican Rx: GOP Alternatives to Hillary Care, Wall Street Jounral, March 23, 2007.
5. Finkelstein, Amy, The Cost of Coverage, Wall Street Journal, February 28, 2007.

As Much As

As much as I enjoy reading in the Wall Street Journal
That future hospitals will be healing places,
I know
There’s no place like home,
As a healing spot to go.


As much as I like the concept
That hospitals will offer home-like amenities.
I feel
There’s no place like home,
As a space to heal.

As much as I love the idea
That hospitals will be healing environments,
I maintain
There’s no place like home,
As an oasis for health to sustain.

As much as I admire the theory,
That hospitals will have no noise, no harsh lighting,
No sharp corners, no environmental stresses,
I believe,
There’s no place like home,
As a chamber for pressures to relieve.

As much as I embrace the hypothesis
That hospitals will have social spaces, gardens,
Acoustical tiles, odor filters, and natural light,
I insist,
There’s no place like home,
As a natural ecology in which to exist.

As much as I know home care isn’t always possible,
That hospitals are needed for adverse conditions,
I pray,
We can make hospitals like home,
As pleasant infirmaries to keep diseases at bay.

As much as I acknowledge the need for care
That hospitals and other institutions supply,
I fear,
Most these dreaded words,
You won’t be going home again, dear.

There’s no place like home.
Unless you need to be in the hospital,
Which, if hospital designers have their way
Will become more like
A home away from home.

1. Laura Landro, Hospitals Set Blueprint for a Better ‘Healing Environment,’ Outdated Facilities Redesign Patient Areas to Lift Quality of Care, Wall Street Journal, March 21, 2007

The Gospel According to Harvard Business School:

Prologue: What follows are thoughts about the influence of Regina Herzlinger, PhD, professor of business administration at the Harvard Business School on consumer-driven health care. These thoughts don’t necessarily represent the philosophy or activities of the Business School as a whole. Another Harvard Business School professor, Michael Porter,for example, has made quite a splash with Redefining Health Care: Creating Value-Based Competition, co-authored with Elziabeth Olmstead Teisburg.

In any event, here goes.

We are the music-makers,
And we are the dreamers of dreams,
Wandering by the lone sea breakers,
And sitting by desolate streams
World-losers and world-forsakers,
On whom the pale moon gleams;
Yet we are the movers and shakers
Of the world forever, it seems.

Arthur William Edgar O’Shaughnessy,
Ode, 1844-1881

This week the March 2007 Harvard Business School Alumni Bulletin crossed my desk. The front cover referred to an interview with Daniel Vasella, MD, “Medicine Man: Novartis CEO Daniel Vasella Makes All The Right Moves.”

As a medicine man, Vasella is an unparalleled mover, shaker, and pill-maker. Three years ago he was named “the most influential European businessman of the past 25 years” in a Financial Times poll of 4000 executives. For good reason. Just this year, Novartis net income rose 17% to $7.2 billion in 2006.

I am personally no mover and shaker as a business person, but I will always be indebted to the Harvard Business School (HBS), of which I am a quasi-alumnus, having graduated as a member of one of its eight-week advanced management programs.

Here, in three parts, are why I'm indebted to HBS.

Part One – Indebtedness – Regina Herzlinger Foreword to Innovation-Driven Health Care (Jones and Bartlett, 2007)

• I spent eight weeks at HBS in 1976 as a student in a program, “Health Systems Management, “ jointly sponsored by the Harvard School of Public Health. It was there I met Regina Herzlinger, PhD, now professor of Business Administration. We have maintained contact off and on for the last 30 years, and she was kind enough to write the following flattering foreword to my book, Innovation-Driven Health Care (Jones and Bartlett), coming off the press on March 29, 2007.

Richard (Dick) Reece is that rare breed of physician commentator who admires his colleagues. How long has it been since you read an article in a medical or health policy journal that applauded the skill and compassion of doctors, scientists, and administrators and/or bemoaned their increasing loss of autonomy to health insurers and governments? Well, you won’t read about how greedy and incompetent they are in Innovation-Driven Health Care: 34 Key Transformations in U.S. Health Care.

What you will read is an intelligent, knowledgeable analysis of the impact of innovations on the future of U.S. health care—and supportive, too. As Dick says, God love him, “being a physician is being part of a brotherhood or sisterhood.”

But why should you read yet another health care future book? Because Dick Reece has nailed it: His view of the future is exactly right. If you want to continue doing what you are doing, this book will enable you to assess how you fit into this new world and to adapt yourself if needed.

I had the good fortune to meet Dick Reece some 30 years ago at the Harvard Business School’s Program for Health Systems Management. Then, as now, Dick was a big man with a gruff affect, piercing intellect, heart of gold, and a sunny, bemused view of life.

I learned of the qualities because I taught accounting in the program, a course that quickly separates the intellectual and emotional wheat from the chaff—the analysts from the analyzed; the “let’s-cut-costs” types from the “let’s–increase-productivity” ones; and those with a sense of humor—believe me, you need this quality in an accounting course—from the deadly serious.These qualities inform Innovation-Driven Health Care.

However, Dick is not merely a cheerleader. He believes that innovations will increase the productivity of the U.S. health care system so that it can provide better services, at a better price, to more people. What a contrast to the usual dour prescribers who contend that innovation is impossible and improved productivity a myth. Their cure? Uncle Sam rations health care. Hello, Canada!

To make the importance of this point of view concrete, consider the following excerpt (Califano, 1977):

Almost immediately (after the introduction of CAT scanning), political objections arose to widespread use of this new imaging technology. HEW Secretary Joseph Califano rose on his political haunches and declared, “There are enough CAT Scanners in Southern California for the entire western United States.”

Not to be outdone, Dr. Howard Hiatt, dean for the Harvard School of Public Health, compared the use of CT scanners to overgrazed medical commons in which too many were foraging for too little. He said a national center for technology assessment and suppression of new technologies should be established and argued (1976):

There is no doubt that the scanners provide additional diagnostic information, and frequently with less discomfort and hazard to the patient, however, it is not clear that the diagnostic information very often leads to a better outcome for the patient. Until this important information is available from careful studies, would we not be better served limiting the use of such expensive technology.

Califano and Hiatt overestimated the power of federal regulations and underestimated the thirst of doctors and the public for this clearly superior technology. Neurosurgeons immediately embraced CT scans. Their enthusiasm soon spread to orthopedic surgeons, who saw the potential of MRIs for joint, bone, and soft-tissue imaging. Most recently, oncologists have welcomed PET scans to check for subtle cancer spread. CT and MRI scanning has become the modus operandi for evaluating all manner of physiological anomalies.

In 2001, 225 internists, when asked to evaluate the relative importance of 30 medical technologies, rated CT and MRI scans as the number one innovation.”

However, Reece is no ideologue. He is a pragmatist. With illuminating case studies, he provides news you can use, as illustrated by the following examples:

How stand-alone, onesie-twosie physician practices can thrive.
• Want to leave medicine? Here is how to make your intellect, training, and experience work for you.
• How to empower consumers and embrace new high-deductible health plans without disemboweling yourself.
• How large groups—Mayo, Kaiser—have avoided “mid-life” crises.
• How to flourish in insurer-physician and hospital-physician relationships, which are more typically akin to the relationship between a salmon and a bear.

I have merely mentioned only five of the 34 topics in this book. If you want to know more, read on!

Why am I so sure that Dick Reece’s views of the future are right? It’s not only that he agrees with my own views, but also, and, more importantly, because he has been right so often before. For example, a dozen years ago, as chairman of a physician hospital organization, Dick created the case-based pricing that payers are finally coming to, some 20 years later. And while living in the midst of managed care–loving Minnesota, Dick predicted the threat HMOs posed to physicians. The observation, which now seems obvious, was radical when he made it—a quarter century ago.

Best of all, Dick’s sunny belief in the transformative powers of innovation are mirrored by his bright, witty writing style. Here are some samples:

Question: What do you call farmers who convert fallow into fertile ground?

Answer: Farmers with a sense of humus.
And on pay for performance: “An ounce of performance is worth a pound of lucre.

It’s great to laugh, especially when the laughter is accompanied by such useful.•

Part Two – Indebtedness – Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers ( Jossey-Bass, 2004)

In 1999 Regina invited me to attend a conference “Consumer-Driven Health Care” organized by Harvard Business School. Ultimately the papers presented at that conference became the basis for her book Consumer-Driven Health Care: Implications for Providers, Payers, Policymakers (Jossey-Bass, 2004). Speaking of the Gospel , in the future this 892 page tome may well be the cited as the gospel that lay the foundation for the consumer-driven movement that was to follow.

Regina served as editor of the book. It had 97 contributors, of whom 25 were physicians. She clearly understood physicians would be central figures in shaping consumer-driven care. As I look back and leaf through the list of contributors and attendees, I realize most movers and shakers of today’s health care world were there and are still around, moving and shaking and developing what is to become a uniquely American system, a blending of private, public, and governmental enterprises.

In 2004, Regina and a Harvard colleague wrote an article in the Journal of the American Medical Association (“Lessons from Switzerland,” volume 292, pages 1213-1220). The article said, in essence consumer-driven care and universal coverage can co-exist. Here is the abstract of that article:

Switzerland's consumer-driven health care system achieves universal insurance and high quality of care at significantly lower costs than the employer-based US system and without the constrained resources that can characterize government-controlled systems. Unlike other systems in which the choice and most of the funding for health insurance is provided by third parties, such as employers and governments, in the Swiss system, individuals are required to purchase their own health insurance. The positive results achieved by the Swiss system may be attributed to its consumer control, price transparency of the insurance plans, risk adjustment of insurers, and solidarity. However, the constraints the Swiss system places on hospitals and physicians and the paucity of provider quality information may unduly limit its impact. The Swiss health care system holds important lessons, including evidence about its feasibility and equity, for the United States, which is now embarking on its own consumer-driven health care system.One of Regina’s “students” in the 1999 Harvard conference was Daniel (Stormy) Johnson, MD., a radiologist, former president of the American Medical Association, and now Board Chair of Consumers for Health Care Choices (CHCC).

In a March 15, 2007, press release, CHCC president, Greg Scandlen, issued this statement:

American Media Ignore Swiss Vote

Single Payer Rejected by 71% of Voters

On Sunday the Swiss people voted overwhelmingly to reject a Single Payer system. But there has been not a word about it in the American press – other than a single paragraph in the trade publication Business Insurance.

The vote was on whether to replace Switzerland’s current system of mandatory health insurance coverage provided by 87 private health plans with a single payer system based on income-related premiums. It was rejected by 71% of the voters.
If the vote had gone the other way – if the Swiss had embraced Single Payer – it would have been front page news in every newspaper in the United States, it would have been a lead story in every broadcast. Reporters would have booked flights to Geneva to interview citizens and political leaders.

This provides a sobering example of why public policy goes so wrong in the United States. The public is informed of only one side of the story. Reporters and editors are biased in favor of government intervention and against free markets. They are part of a privileged elite who think consumers are incapable of making sound decisions and intelligent choices.

But the people of Switzerland made the same choice as the American people make every time they have had an opportunity. Voters in Oregon rejected Single Payer by a vote of 79% to 21% in 2002. People do not want to be herded into a government-run cattle car. We want and demand freedom of choice in health care as in every other aspect of our lives.

• Part Three – Indebtedness – Daniel Vasella, MD, Interview

Lastly I am indebted to Harvard Business School through its publications for continuing to recognize that health care is a driving, uplifting force in the U.S. and international health economies. Indeed, within 20 years, health care may be the economic engine for 25% of the U.S economy, as it already has in Minnesota, where it is that state’s number one employer.

The interview highlights the insights and contributions of Dr. Daniel Vasella, who rose from a clinician in Bern, Switzerland, to work his way up through the marketing division of the Swiss conglomerate Sandoz. Within a decade, Vasella, who did a stint at Harvard Business School advanced management course in 1989, was leading Sandoz’s merger with Ciba-Geigy. The merged company was named Novartis. Vasella became CEO of Novartis in 1996. Today, Novartis ranks no. 4 among international drug companies with sales of $37 billion. Under his leadership, the company has led the industry in new drug approvals. It now has 138 new drugs in its pipeline. Novartis has also diversified into vaccines and generic drugs, setting it apart from rivals.

Among the observations and insights Vasella offers in his interview are these.

• Drugs make up 15% to 18% of health costs but account for about 40% of the drop in disease mortality. If we were to strip all the profits from the industry, it would drop overall health costs by just 3%.
• The Medicare prescription drug program has been a success, despite Democratic criticisms that it relies too much on private insurance providers. Costs have been lower than anticipated, and, says Vasella, “The system seems to work pretty well.”
• Novartis has succeeded in developing new products by creating a culture of innovation by integrating research and marketing and by nurturing project teams to move drug development forward.
• Novartis has moved its research headquarters to the U.S, so it work more closely with academic institutions, has created a genomic institute in La Jolla, and in 2002 formed the Institutes of BioMedical Research in Cambridge, Massachusetts.
• Novartis has invested heavily into generic drugs. These drugs have less profit than brand names but are growing more rapidly. People are rapidly switching from brand drugs to generics to cut expenses. “Our philosophy is to link for sustainable growth and to create and maintain a business that is competitive and that satisfies the needs for society and customers.”
• Novartis has moved into vaccines big time because of high growth rates of 15 to 20% and because other companies had abandoned vaccines due to litigation problems. This adversarial legal climate has changed recently, The U.S. government has recognized nobody wants to produce vaccines anymore and loosened litigation rules,
• Novartis is cautious about supplying low-cost drugs to poor countries because it cannot fix poor governance, corruption, inadequate distribution systems, and lack of health-care professionals. Even so, Novartis is delivering services and products worth $700 million to these countries, about 2% of its sales. Vasella says one cannot punish patients because of bad government, but it is not the responsibility of private companies to compensate for bad government.

Summary

Regina Herzlinger, PhD, Professor of Business Administration at the Harvard Business School, has helped nurture a group of physician movers, shakers, and pill-makers to lead consumer driven health care. This type of care may develop into an integral component of U.S. and international health systems. Consumer- driven care assumes empowered consumers will have more choice, more control over care, and lower costs with higher quality. It also takes for granted consumers will willingly take more responsibility for their health and will become more informed health care consumers.

Medical Jargon: Measure It, End It, Create It

Jargon -- SPECIALIST LANGUAGE that is used by a particular group, profession, or culture, especially when the words and phrases used are not understood or used by other people.

Encarta World English Dictionary, St. Martin’s Press, 1999

Herein lies two “how-tos.”

1) How to measure and end medical jargon when speaking or writing for patients. I call this process “jargonoughting.”

2) How to create medical jargon to impress your fellow physicians. I call this process “jargonauting.”

I do this because I believe one fundamental innovation that will change health care will be translating medical jargon into language patients can understand. This will facilitate patient education, overcome patient illiteracy, make medicine more effective, and reduce misunderstandings between doctors and patients.

Michelle Sobel leads a creative team at Emmi Solutions. This Chicago company produces interactive online visual programs narrated in plain words to inform patients what to expect from surgical and chronic disease episodes. Michelle has mastered the art of converting medical jargon into plain language. The language in the Emmi programs are phrased and written at the sixth grade level.

But how, you may ask, can I, as a doctor, be sure I’m writing at the sixth grade level? I don’t know Michelle’s secret. But as for me, I measure my jargon by using the Fog Index. Yes, the Fog Index? In 1968 Robert Gunning, a consultant who advised publications how to write in language people understood, devised this numeric index.

To find the Fog Index of a piece of prose:

1) Calculate the average number of words in your sentences (or complete thoughts linked by punctuation marks);

2) Count the number of three syllable words per 100 words (don’t count proper words, combinations of short words (e.g manpower) or verb forms made into three syllables by adding –ed, -es, or –ing.)

3) Add 1 and 2 and multiply by 0.4 to get the Fog Index.

Let’s say the Fog Index is 6. Six reflects the grade level it takes to read with ease a given passage.

Jargonought, and Fog Index

To give you a feel for the Fog Index, let’s count it for a well-known biblical passage.

I returned and saw under the sun, that the race is not to the swift, nor the battle to the strong, neither yet bread to the wise. nor yet riches to men of understanding, nor yet favor to men of skill, but time and chance happen to them all.

Fog Index

1. 7-8-6-7-6-7-8=49/7=7.0
2. 1=1.0
3. Fog Index= 7.0+1.0 x 0.4= 3.2

Now let’s take a GI group’s paper instructing a patient how to prepare for an intestinal endoscopy exam.

These are instructions for your endoscopy preparation for tomorrow in the operative suite at our endoscopy facility. You are now scheduled to have an examination of your lower and upper intestine with the use of a lighted flexible tubular instrument called a endoscopy scope. You will be administered medication prior to your examination that will enable your physicians to perform the test with as little discomfort to you as possible. Please be aware of the medication's sedative properties. Because of these sedative effects, you must make arrangements for someone to accompany you home or to your apartment or condominium after the procedure.

1. 17-27-26- 8-24= 102/5= 20.4
2, 102X 29/91=28.4
3. Fog Index = 20.4 + 28.4 X 0.4 =19.5

Using the Jargonought technique, this passage's Fog Index could be reduced.

You are scheduled to have an exam of your colon and upper bowel., We will use a lighted tube called an endoscope to do this. You will be given a drug to put you at ease. This drug will sedate you. So we ask you bring someone to drive you home.

1. 13+12+5+10 = 10.0
2. 1= 1.0
3. Fog Index= 10.0 + 1.0 X 0,4 = 4.4

Jargonaut, Or Mixing Wind and Fog

Where do physicians learn to use jargon? They learn it in medical school. Jargon is a contagious disease. Doctors catch it early on in academic medical centers where the “public or perish “ phenomenon flourishes. Then jargon spreads, becomes endemic, then epidemic as doctors seek to impress one another. Unfortunately jargon is hard to stamp out, and doctors may lapse into using it when talking to patients.

To show how to practice jargonaut, and to become a jargonaut, I wrote this piece for the Journal of the American Medical Association.

Space-Occupying Gambits for Medical Writers

As a rule, disease as it stalks through the land cannot keep pace with the incurable vice of scribbling about it.

John Mayo, de Rachitide, 1668

Space-occupying prose diffuses through medical writing like a fog. Yet space-consuming efforts of some of us continue to be rejected. The message of this essay is that obscurity, when properly inflated, can lead to publication. Your goal is clear – to produce the greatest number of papers from the minimal amount of data using the maximal number of words.

Windfoggery Weave

Windfoggery is the bedrock of all obscurity. Wind and fog don’t coexist in nature. But they can be woven together on the printed page. Give the reader a low-fact diet with high-jargon content. Sprinkle with polysyllabic words. Scramble the syntax. If you doubt a predecessor’s methods, don’t say: “Jones’ methods are questionable.” Deepen the fog, and raise the wind velocity by saying: “The quantitative variables assayed by Jones were analyzed and scrutinized and appeared, according to our interpretations, to demonstrate significant fluctuations, which seems to vacillate diurnally.” Note the murky merging of wind and fog.

The Retrospective Ramble

In the retrospective ramble, pay homage to the past by exhaustively reviewing your subject, The flood of references will inundate the editor and drown the reader. Refer to inaccessible, outdated, or foreign journals. This adroit maneuver discourages and diverts critics. Their futile search through back alleys of print will wear down objectivity. It will blur perspective. Complete your conquest over comprehension by quoting everything ((or nearly everything) that has been said about your subject. Whether the material is relevant isn’t important. It’s the number of references that count. It’s wise not to be discretely excessive. The discerning editor will quickly reject such a clumsy effort as this.

“I 26,31,14 believe that21,88 this technique25,85,99 of using excessive references 922 to previous papers is abused 71,02, 502 by most authors, 28,192,617 particularly myself1,22,3581,269 in my exhaustive reviews of articles, 67-84 all of which have been rejected by numerous journals.0

The Humble Hedge

The humble hedge is a gambit whereby you qualify your meaning into nothingness while appearing to be objective. Always convey doubts about your statements. Arrange a retreat from clarity with hedge verbs like indicate, suggest, appear, may, and might. Withdraw with these nouns: speculation, conjecture, theory, and hypothesis. Hedges can be classified as first, second, and third order or as single, double, and triple barreled. A fourth-order or quadribarrelled hedge is clumsy and should be avoided. A fifth-order hedge, such as “Speculation about etiological factors might possibly suggest that previous investigators may have been wrong some of the time.” is excessive and poor form. The sentence could be reduced to a third-order hedge with only slight loss of ambiguity.

The Passive Ploy

In the passive ploy, place yourself in the background. Stress vague pronouns, fuzzy facts, and lofty concepts. To do this, write in the passive voice. You can add words, befog your meaning, and become a detached sage. It was discovered by the author is nearly 4 ½ times longer than I found and is more humble. It was reported by this investigator in a recent publication requires eight times more space than I noted and is more sedate. But, how, you may ask, can I be sure I am writing in the passive voice? You could consult books of grammar, but most doctors are too busy for that sort of thing. So I have gathered together some practical suggestions.

• Commence you sentences with impersonal remarks –It is though, it is believed, it is felt.• Strip your sentences of verbs which picture or imply action .
• Glue your thoughts together with have, seem, or some form of to be – is, are, was, were.• Delete the personal pronouns – I or we.
• Strew your sentences with whichs, bys, or ofs.

The passive voice allows you to avoid straight statements. The true scientist is never direct or blunt. Use the passive voice often. It is the most space-occupying weapon at your command.

The Word Wedge

Word wedging is art of forcing big words into sentences where they don’t belong. The careful wedger picks his tools. He prefers abstract terms with scientific overtones – armamentarium, congeners, continuum , dynamic, esoteric, kinetics, methodology, modality, oncogensis, parameter, sophisticated. If the wedger is clever, he will drop bureaucratic buzz bombs by intermixing any of the following words in these three columns in any combination.

1 2 3
total management care
regional supportive coordinator
universal health analyses
primary integrated centers
comprehensive ambulatory services
national resource priorities
quality pilot planning
interdependent involvement needs
preventive paramedical studies
systematized effective utilization
feasible digital implementations
delivery scientific objectives
unmet outreach systems
community multidisciplinary maintenance
centralized medical parameters
longterm multiphasic feedback

The following example of wedging if from an article in a well-known medical journal,

Substances which are immunologically foreign are composed of autohochthonous materials. These are not diagnostic, but with progressive increase as seen by serial samples, in association with other suspicious parameters, electrophorectic pattern may become significant as a predictor.

Observe the passive mingling of windfoggery, hedging , and wedging – all combining to produce hieroglyphic obfuscuity.

The “That” Thrust

Put this gambit into play by thrusting the word “that” into the start of your sentences. With “that,” you can introduce your sentences, qualify your thoughts, blunt your meaning, express wonderment, and consume thought. Let me show what I mean with these examples – It is fascinating to note that, in spite of the fact that, It is often the case that, But it may be possible that, There can be little doubt that, It is interesting to observe that. Not the running start. Each example consists of six word obstacles the reader must traverse before he reaches the beginning of the sentence. Think of “that” as a suitcase word. Whenever you use it, you carry along verbal baggage, and “that,” after all, is your mission – your main game.

The Verb Void

Save this gambit for your first revision (a second revision is rarely necessary in jargon-filled space –occupying writing). Read over your paper. Look for verbs that can be changed into nouns, Void your sentences of vulnerable verbs. Then rearrange the entire sentence. Study these three examples to see how they gambit works.

Before Revision – Then we decided to explore the other possibility (8 words).

After Revision – Then the decision was arrived at that an exploration of the other possibility was advisable (16 words, 100% increase.

Before Revision – We investigated what causes cells to mutate (7 words).

After Revision –We then made an investigation of what the causes were for the mutation of the cells (16 words, 130% increase).

Before Revision – Surgeons enlarge the cavity by incising laterally.

After Revision –The best means for enlargement of the cavity by surgeons is by means of a lateral incision (18 words, 160% increase)

As a beginning gamesman, you’re no doubt impressed most by the increase in the number of words. With experience, you will realize another virtue of the verb void – it breeds other gambits. In the last example above, the passive play came into play. Finally, the act of trading active lean verbs into edematous, sedentary nouns is always good gamesmanship.

The Double Dawdle

The double dawdle permits the gamesman to double his world volume while keeping his facts constant. This gambit has two variations -- the supersuperlative dawdle and the redundant dawdle. Execute the supersuperlative dawdle by adding the words very, markedly ,tremendously, much, quite to your adjectives. If you’re describing a big uterus, you can call it a very enlarged uterus, a quite enlarged uterus, a markedly enlarged uterus, a tremendously enlarged uterus, or a much enlarged uterus. Beware of the triple or multiple dawdle. A “very much markedly enlarged uterus of tremendous size” wouldn’t likely slip through the editor’s net. Only you and the reader will appreciate the profundity of your distinction. Perform the redundant dawdle by joining such words as equal halves, hazardous risks, linear lines, and tumor masses. You appear to be reinforcing your meaning, but you are really just duplicating words.

The Paragraph Parry

When you have a large space to fill, word gambits are good, but paragraph parries are better. Open your paragraph by sallying forth with a decisive sentence. The reader, caught off guard, will plunge into the paragraph. Immediately parry with a series of indecisive sentences. What you give away in your opening, take back in the discussion. Begin with courage. End with prudence. What more could be asked from a dignified scientist. Here is an example of a paragraph parry.

I define cerebral palsy as any paralysis, weakness, or incoordination, or dysfunction resulting from brain damage. Jones, however, regards cerebral palsy as and condition characterized by paralysis, weakness, incoordination , or other derangements of motor function due to pathology of motor control centers of the cerebral cortex. On the other hand, Smith’s definition is more comprehensive, “Cerebral palsy is a condition occurring from birth trauma and resulting form interference with the motor system and leading to neuromotor dysfunction, psychological aberration, atypical convulsions, and behavior disturbance of organic origin,” It is obvious that the brain is a complex organ subject to varying degrees of damage which are manifest in unusual disturbances interpreted in various fashions by different, independent observers.

The writer’s opening sortie is a crisp definition. He then counters with two meandering redefinitions and completes the gambit by admitting hopeless confusion.

Finishing Finesse

Employ the finishing finesse in the backwaters of the discussion and in the stagnant summary. Only the able gamesman should handle this gambit, for he must manipulate ideas that were never expressed. The finishing finesses may be defined as the use of large words in loose phrases to achieve a wandering endings, e.g.

The pathogenesis of the diverse forces operative in electrolyte disturbances were studied, and it was concluded that the variability of the methodology did not permit delineation of the therapeutic modalities.

Observe that the writer ends by hovering above the concrete by talking in abstractions, and the readers ends where he started – fogbound.

I know what you’re thinking – what’s the Fog Index of this essay he just tried to fog by me.

The answer is:

1) 2456/262 = 9.3
2) 346X100/2256= 14.1
3) Fog Index = 8.7 + 14,0 X 0.4 = 9.4

Innovation and Conservative Risk Taking - SHAPE Example

In an earlier blog, I said I would return from time to time to excerpts from The Daily Drucker (HarperBusiness, 2004). This handy little book contains daily entries consisting of excerpts of writings of late Peter D. Drucker, America’s most eminent managerial and social philosopher.

I have patterned mediinnovationblog.blogspot after Drucker’s work. Each day I make an entry based on something I write that day or something I’ve written in the past, always something that relates to innovation in health care.

What follows are: A) One of Drucker’s daily entries; B) One of my daily entries.

A) Drucker Daily Entry

Successful innovators are conservative

I once attended a university symposium on entrepreneurship at which a number of psychologists spoke. Although their paper disagreed on everything else, they all talked about an “entrepreneurial personality, which was characterized by a propensity for risk taking.” A well-known and successful innovator and entrepreneur who had built a process-based innovation into a substantial worldwide business in the space of twenty-four years was then asked to comment.

He said, “I find myself baffled by your papers. I think I know as many successful innovators and entrepreneurs as anyone, beginning with myself. I have never come across an ‘entrepreneurial personality.’ The successful ones I have know all have, however, one thing – and only one ting – incommon: they are not ‘risk takers.’ They try to define the tasks the risks they have to take and to minimize them as much as possible. Otherwise none of them would have succeeded.”

This jibes with my own experience. I, too, know a good many successful entrepreneurs. Not one of them has a “propensity for risk taking.” Must successful innovators in real life are colorless figures, and much more likely to spend hours on cash-flow projections than to dash off looking for “risks. They are not risk –focused”’ they are “opportunity focused.”

ACTION POINT: Determine which of your ideas the least risk and the most opportunity and focus on them.

B) Reece Entry

What I’m about to describe is a remarkable innovation that’s conservative, not risky, and destined for success. It’s a cardiovascular-pulmonary risk device, based on tweaking and modifying the current cardiac risk treadmill stress test but without the risk and with additional pulmonary and predictive risk software.

It’s not risky because:

1) it carries no risk for the patient;

2) it is based on five decades of research;

3) it has been tested and validated at the Mayo Clinic, which is not in the habit of recommending risky devices.

Catching Bad Behavior Early a Risky Proposition

Preventing predictable disease is a risky proposition. You can preach and teach, hector and lecture, fan flames of fear, and even ban bad behaviors in public places. As a general proposition, banning bad behavior is a good thing, but as Oliver Wendell Holmes, Jr. said, “I dare say that I worked off my fundamental formula on you that the chief aim of man is to frame general propositions and no general proposition is worth a damn.”

Nothing, it seems, can change bad behavior for everyone. Banning individual pleasurable behavior in a capitalistic society is a risky proposition, for it impinges on individual freedom. Public banning sound simple, but as alcohol and marihuana prohibition has taught us, defying banning is exciting and often leads to abuse.

Innovative Way to Influence Behavior Leading to Heart and Lung Disease

But there may be an innovative way out. One can measure the early physical effects of bad behavior. After all, whatever can measure can be understood – and managed. That is why the mantra of “metrics” marches through the minds of medical managers. The subjective becomes objective and understandable to common man.

SHAPE

Suppose you had a portable high tech – simple-to-use, economical, low-risk device – that could measure early bad behavioral effects, lack of fitness, early signs of heart and lung disease, engendered by smoking and obesity.

Suppose these “metrics” were objective, reproducible, and understandable to those doing the testing and those being tested. And suppose you could “quantify” chances for hospitalization and even early death, based on a large irrefutable database of hundreds of thousands of patients that have gone before you down the paths of preventable bad behavior. Now, that would be “Innovative,” with a capital “I.”

What I’m building up to is a new technology called SHAPE – Superior Heart and Pulmonary Technology. A group of four (who prefer to go unnamed for now until the scientific evidence is irrefutable) – an electrical engineer, an electrophysiologist, a software programmer, and a health care consultant – known as Cardiac Risk Assessment Associates, have been working in conjunction with the Mayo Clinic department of Cardiology, to develop a physiologically-sound, scientifically-based, and computer-predictive device for evaluating cardiopulmonary disease in multiple settings.

The device will be small, non-invasive, accurate, and will yield reproducible results. The device results from four or five generations of evolving cardiac and pulmonary testing devices. It is evolutionary as well as revolutionary, and it may prove to be effective for detecting early disease, modifying or preventing behavior that led to heart or lung dysfunction, and measuring responses to behavior change or therapy.

Here is how the four associates explain their device.

Cardiac Risk Analysis Associates (CRAA) had developed an advanced cardio- pulmonary testing procedure called SHAPE (Superior Heart and Pulmonary Evaluation). It is non-invasive, convenient, safe, and economical. The test is designed to evaluate and quantify a person’s cardiac and respiratory efficiency not unlike the stressful and risk-prone procedures presently performed in the specialists’ medical offices of today.

The technology represents the next generation of cardio-pulmonary function evaluation. The device includes a stair step, a mask with sensors, an analyzer and a dedicated laptop computer.

The test utilizes inspired and expired gas analysis measured against workload and time. It utilizes newly developed components of pulmonary testing and computerized software and display that result in proxy indicators of organ health and predictive diagnostics.

SHAPE measures the functional “fitness” of a patient’s heart, lung and vascular systems as these organs work together to support activities of daily living, functionality capacity, and one’s capacity for exercise. Its convenience and low costs allows monitoring of therapeutic response to medications, exercise and patient compliance. Additionally, the device is used as a diagnostic screen for cardiac pacing implantation and the calibration and recalibration of such.

The test is a technological advancement over present pulmonary and peak exercise stress testing. As technology advances, SHAPE affords a ‘better, faster, safer, easier, cheaper’ alternative solution to yesterday’s practices. It is designed for use in a primary healthcare setting, utilizing paraprofessionals. It is deemed risk-free and requires a minimum of space while in use or in storage. The device is self-calibrating and requires the patient to perform only a minimum exertion over one’s resting heart rate.

Primary care and health screening is in present need of objective measures of functional heart-lung diagnostics. Present day cardio-pulmonary testing is costly to the system and resides in the domain of the specialists. Early diagnosis and control of obesity and complications due to sedentary life styles are major drivers of costly disease and attendant chronic disease. SHAPE enables early objective classification of preventable disease.

SHAPE provides predictive data for physician evaluation of patient risk for morbidity, mortality and future hospitalization.

If you’re like me, you may think of innovation as something new – some revolutionary breakthrough. However, in the real world of health care, most breakthroughs come from evolutionary rather than revolutionary changes, or from combining past technologies to form a new innovation to address some current health crisis.

The Crisis – Deaths from Health and Lung Disease

Consider deaths from vascular or lung disease as that crisis. In 2004, the four leading causes of death were heart disease, 654,092, cancer 550, 270, stroke 150,147, and chronic obstructive lung disease, 123,884. Of these deaths, more than 400, 000 are related to smoking.

The Need for a Device Combining Heart and Lung Testing

These statistics indicate the need for some innovative device to test for heart and pulmonary disease in its early reversible stages, particularly in smokers – the number one environmental preventable cause of death.

Would it not be of great benefit to the health system, then, for some device that had some of the following characteristics?

• Something of no risk to individual subjects while the testing is being carried out.
• Something not requiring the presence of a physician in attendance during testing.
• Something mobile and small that could be used in multiple settings – the physician’s office or a health club.
• Something less expensive than current testing devices.
• Something combining heart and lung testing.
• Something that could measure both cardiac and pulmonary fitness.
• Something sensitive enough to measure early heart or lung damage from lifestyle behaviors that could be stopped...
• Something that could be repeated often and that could measure the response to therapy.
• Something based on large predictive databases that would indicate future risks of hospitalization or death.
• Something derived and modified from existing proven technologies...

Current Common Testing Methods

With regard to the last point,

• The principle device currently used for testing for health disease has been cardiac stress testing, using a treadmill, and sometimes driving the subject to near exhaustion to check for cardiogram changes indicating cardiac ischemia from coronary artery disease. The type of testing carries the risk of inducing fatal arrhythmias while on the treadmill, requires a physician in attendance, requires bulky space-occupying equipments, and lacks sensivity to detect early cardiac and pulomonary diseases in one setting.

• In the office pulmonary testing , physicians often rely upon a spirometer, an apparatus for measuring the volume of inspired and expired air in the lungs. The output produced by a spirometer is called a kymograph trace. From this, vital capacity, tidal volume, breathing rate and ventilation rate (tidal volume x breathing rate) can be calculated. From the overall decline on the graph, the oxygen uptake can also be measured.

What If’s

What if practicing physicians and concerned patients had access to such a small device – consisting of nothing more or less than a stair step, a mask with sensors, a gas analyzer, and a laptop computer – to replace current equipment used for cardiac stress testing?

What if. this device accurately evaluated integrated heart and pulmonary function and distinguished between the two; estimated efficiency of these two vital organs after two or three steps up a stair step?

What if the device yielded an evaluation of heart and lung function within 15 minutes; produced quantitative prognostic information, based on a database carrying information from thousands of previous patients, such as risk of death and risk of hospitalization; could be repeated at will with no risk to the patient; was less expensive than current cardiopulmonary testing; proved to be superior to existing “gold standards” – cardiac ultrasound for assessing left ventricular function at rest and cardiac pulmonary exercise tests for assessing functional capacity during exercise.

Well, such a device may soon exis.

A word of caution. A blog, this blog in particular, isn’t a scientific report. It is, however, based on solid speculation and documentation about an exciting innovation, resting on data generated by fifth generation devices for measuring heart and lung function. It shows the power of informed and evolutionary innovation.

Health Care Organizations: Select a Chief Innovation Officer

Within five years, I predict health care organizations of all sizes, shapes, and functions – health plans, hospitals, medical practices, support groups, consultants, supply chain vendors, health care associations, consumer groups -- will select someone within their organization to be their chief innovation officer.

The chief innovation officer will generate ideas, sift through them, pick winners, and lead organizations towards a future geared to productive change.

Right now only a handful of health care chief innovation officers exist – at the health plan giant, Humana; at Alegent Health, midsized hospital system in eastern Nebraska and western Iowa, and at Cadient Group, a health care marketing agency. No doubt other Chief Innovation Officers exist that have escaped my attention, but there are still too precious few Chief Innovation Officers.

Many health leaders are already serving as functional Chief Innovation Officers – CEOs and CIOs of hospitals and health plans, Chief Medical Officers, physician leaders, nurse executives, nurses and managers in physician offices. I don’t really care what title these persons bear, or whether they call themselves Chief Innovation Officers, Chief Information Officers, Chief Inspirational Officers, or Chief Instigation Officers, as long as they create, generate, foment, elicit, implement, filter, and test out new ideas.

The CIO’s chief functions are to stimulate, generate, and instigate ideas, principally from below – from managers, employees, people on clinical front lines, patients, staffs in medical offices, from consumers and the public at large. Workable new ideas generally do not not come from the top rungs of an organization, but from lower and bottom rungs, from service and interactive personnel on the front lines of care.

The CIOs other functions are to keep ideas flowing and to try them out, again and again, failing again and again, then starting out again. My favorite definition at the moment for “innovation” is this one, which I read in the March 20 New York Times.

Innovation is a constant process of trial and error. You need the willingness to fail all the time. You have to generate many ideas and then you have to work very hard only to discover they don’t work. And you keep doing that over and over until you find one that does work (Steve Lohr, “John W. Backus, 82, Fortran Developer Dies, March 20, New York Times).

John W. Backus assembled and led the I..B.M team that created Fortran, the widely used computer program language that opened the door in 1957 to modern computing. Perhaps this is my favorite quote because in the late 1960s, Russell Hobbie, a professor of physics at the University of Minnesota and I, used computer software, which Hobbie wrote in Fortran, to create a program that generated a differential diagnosis for abnormal laboratory results of some 600 tests that was used in 6 million laboratory reports.

What does a chief information officer do? Jonathan Lord, MD, chief innovation officer of Humana since 2002, says,

The CIO becomes the spiritual leader within the enterprise. His basic role to bring new ideas into health care and to find talented people who can handle ambiguity and who have passion for change – people who have comfort with new ideas, who can align beliefs, and who can co-create.

The CIO, in short, constantly co-generates idea, keeps the ideas flowing, and tests them out to see if they work or fail.

Harry Lukens, Chief Information Officer of Lehigh Valley Health Network in Allentown, Pennsylvania, has developed and chaired a group he calls the “Wild Idea Team.” It has a rotating membership of 18 to 25 people, at all levels of the organization. The team places no ideas off limits, and there is only one rule “no snickering.”

Health care needs more Harry Lukens.
Who take positively nothing for givens,
Who tolerate no gratuitous snide snickering,
Who forbid all internecine biased bickering,
Who believe out there lies some wild idea,
That may very well the key to the future be a.

Data Mining, Predictive Modeling, and Innovation: Keys to U.S. Health Reform

Modified From my origina article in HealthLeaders News, June 27, 2006

Definition of Data Mining

The nontrivial extraction of implicit, previously unknown, and potentially useful information from data.

AI Magazine, Fall, 1992

Definition of Predictive Modeling

A process by which a clinical database is used to describe mathematically the likelihood of outcome events, given a set of variables on a new patient.

Liposcience, Inc, 2007

In “The Consequential Divide: Which Direction Healthcare?” (April 27, 2006), HealthLeaders contributor Preston Gee asserts a political divide exists between market-driven and single-payer advocates who seek to resolve cost, coverage and quality problems.

Either solution, the title implies, harbors profound consequences for health care stakeholders. It’s possible a powerful force embedded in American culture--our genius for innovation--will bridge the divide.

A New Solution

Experts point to five basic reform solutions that exist for the U.S.:

• A national universal system of coverage
• A consumer-driven, market-based system covering those able to pay
• State-by-state universal coverage, Massachusetts-style
• A national consumer-driven, market-based model with universal coverage through Federal Employee Health Benefits Plan or the Universal Health Voucher Plan, as proposed by the Mayo Clinic
• A modification of the current system, using managerially guided information technology systems to control supply costs, measure outcomes, reward performance, and control behavior of health plans, hospitals, doctors, and consumers.

I propose another approach incorporating all these solutions--systematic innovation by government and market-based organizations. This solution will take time. It overlaps government and private sectors, and it is not without doubters. George Lundberg, M.D., past editor of the Journal of The American Medical Association and now editor of Medscape’s MedGenJournal, observes, “Innovations tend to be limited and localized. For the masses, innovations would have to propagate like crazy.”

Comparisons Across The Pond

In Innovation and Entrepreneurship, Peter Drucker argues the U.S. entrepreneurial economy distinguishes us from Western Europe. Our current economic growth rate is 4 to 5 percent while Europe’s is 1 percent. The U.S. unemployment rate is half of Europe’s. To Drucker, such differences exist because U.S entrepreneurs are closer to customers while socialistic bureaucrats are isolated and remote from people.

Critics argue that Europe has universal coverage and better health statistics. True, but it’s at the cost of economic stagnation, long waits and limited access to medical technologies. One could persuasively argue U.S. innovations often are strictly technological in nature and have little to do with solving social problems ranging from the uninsured to high cost and poor quality. But I assert that these problems can and will be addressed in innovative ways in the political, data collection and deployment, information technology and healthcare organization arenas.

Major Innovations

Six major innovations, sometimes inspired by government, sometimes undertaken independently or in concert with the private sector, are driving health reform: data mining reform, consumer-driven care, pay-for-performance initiatives, national electronic infrastructure building, state-by-state reform experimentation, and “disruptive simplification” innovations at the practice management level. Data mining is the most important and sweeping innovation, because it gives us the tools to restructure and rebuild the existing system based on irrefutable and impersonal data.

According to Webopedia, the computer technology dictionary, data mining may be defined as “the class of database applications that look for hidden patterns in a group of data that can be used to predict future behavior. For example, data mining software can help retail companies find customers with common interests. The term is commonly misused to describe software that presents data in new ways. True data mining software doesn't just change the presentation, but actually discovers previously unknown relationships among the data.”

Four areas of data mining are transforming healthcare:

• Medicare data mining

This form of data mining is not new, but it remains an inexhaustible innovation source because of its size. John Wennberg and Alan Gettlesohn first explored the Medicare Mine in 1973 when they published their classic findings on how medical care varied from one region of the country to the other. Ever since, Medicare data has been considered the sine qua non for studying and judging health costs and outcomes. Wennberg considers medical service variation across regions and academic center as “unwarranted.” The variation data, he concludes, does not correlate with better outcomes data. He has proven beyond statistical doubt that “more is not better.” Employers and health plans are aware Medicare data is a treasure trove for data miners wishing to improve quality and outcomes and to pay hospitals and doctors for performance, which is why the Business Round Table and others are pressuring the Bush administration to release all Medicare claims data.

• Pharmaceutical data mining

I was present in Minneapolis in the 1970s at the creation of the UnitedHealthcare Group. Perhaps that is why I maintain that pharmaceutical data mining, outside of the billion- dollar leadership of William McGuire, M.D., is what made UnitedHealthcare what it is today. It isn’t generally recognized that 75 percent of United’s profits come from outside the traditional HMO business. In 2005, I spoke with Brian Gould, M.D., a former senior executive for United. “In early 1990, I moved to Minneapolis. I was in charge of United’s Specialty Operations Division--all the non-HMO businesses. These included a pioneering pharmaceutical benefit company, Diversified Pharmaceutical Services. In 1993, we sold DPM to Smith Kline Beecham for an astonishing price of $2.3 billion,” he said. Under the terms of agreement, United HealthCare agreed to provide Smith Kline Beecham “with access to medical data and outcomes analysis.” This meant access to United’s pharmaceutical data mining operation data. For example, if United had pharmaceutical claims data indicating who was taking insulin, Smith Kline could use that data to study a huge population of diabetics.

United has not abandoned pharmaceutical data mining. Its Ingenix division provides clinic research services, medical education services, and therapeutic outcomes and epidemiology research data to pharmaceutical companies, biotechnology companies and medical device manufacturers.

• Printed Word Data Mining

Google is so powerful, it has become a verb. One no longer looks up information in medical libraries, one “googles” medical information. Google, I would argue, is turning the medical world upside-down. Medical journals, for example, are struggling to survive because of drops in advertising and readership. Moreover, Google has leveled the information playing field between doctors and patients. The late Tom Ferguson, M.D., a pioneer and prophet of the consumer-driven movement, put it this way in an interview I conducted with him in 1999: “Patient knowledge is different from physician knowledge. Depending on the area of specialization, a specialist might have to stay current on 30, 200 or 400 medical conditions. A general practitioner might have to keep up with 600. Patients only have to know about one disease--their own.”

• Clinical, Practice Management and Practice Pattern Data Mining

In the 1970s and 1980s, in a clinical laboratory setting, Russell Hobbie, Ph.D., a physics professor at the University of Minnesota, and I used the Internet to develop two practical clinical applications using data available in physician’s offices--patient age and gender, physical measurements (height, weight, blood pressure), and laboratory data. From this universally available data, we developed two products--the Unified Presentation of Relevant Tests, a differential diagnosis report listing the top ten diagnostic possibilities, and the Health Quotient, a health status report based on height, weight, blood pressure, family or personal history of heart attack or stroke, and laboratory findings. UNIPORT was 80 percent accurate and was commercially successful; the HQ was acclaimed by its recipients and predicted imminent heart attacks with unexpected precision.


True Potential

The real potential of data mining lies in practice pattern grouping using existing data to define costs and consequences, and predictive modeling using broad clinical and financial databases to define the effect of current patient behavior, diagnoses, and interventions on future outcomes and costs.

Practice pattern grouping often goes by the name of episode grouping. As government and private healthcare organizations seek to deliver top-quality care more cost-effectively, episode grouping has come into vogue. By clustering costs around a clinical episode--everything from doctors involved, to diagnoses, to medications, to interventions, to hospitalization, to rehabilitations, to nursing home care, to outcomes-- you can more precisely analyze total outcomes and costs. You can also more accurately—and fairly—assess physician performance.

Much of the total cost, for example, of hospitalizations resides in the hospital’s costs. Hospital charges make up about 80 percent of physician costs in the hospital setting. The hospital charges may be beyond the doctor’s control. On the other hand, drugs doctors prescribe or interventions they choose are not. It has been found that total episode costs may vary by factors of as much as 20 to one. In these instances, and even with smaller variations, systematic or structural reforms are in order. True reform lies in rationalizing, not rationing, care.

Predictive Modeling

Predictive modeling requires a more sophisticated mathematical approach and artificial intelligence deployment. One of the pioneers in this field is David Eddy, M.D., Ph.D., who, over the last 10 years at Kaiser Permanente, has developed a predictive model called the Archimedes Model. This model provides a mathematically based lever that moves and manipulates vast amounts of data in a way that simulates reality. It improves and speeds healthcare decision-making at decision points along the healthcare spectrum. Archimedes, funded by Kaiser, has been 10 years in the making. It uses mathematical simulation to create a visual world to help healthcare organizations make critical and administrative decisions. The model has been repeatedly tested and validated to answer complex real-world decisions. In the words of a Kaiser publicist, “The Archimedes model has virtual people who get virtual diseases, go to virtual doctors, get virtual tests, receive virtual treatment, and have virtual outcomes.” Using Kaiser’s eight million-member database, Archimedes played a role in the Vioxx recall, and it is currently being used as a tool to conduct virtual clinical trials by major pharmaceutical companies.

Another company pursuing goals similar to Archimedes is MedAI (short for Medical Artificial Intelligence) in Orlando, Fla. MedAI’s outcomes measurement application, Pin Point Quality, enables users to easily identify specific steps to monitor and improve clinical outcomes while reducing healthcare costs. Clients can integrate data from clinical and financial legacy systems. This allows clients to undertake quality initiatives. Medical directors, administrative directors and other members of the organization can create reports of quality indicators, which they can then use to drive practice changes in their organization.

In formulating the argument that America innovation in general and innovation in the handling of data in particular will change the world, I have only touched briefly on such innovative and powerful movements as consumer-driven care, pay-for-performance, the building of a national electronic infrastructure, the political innovation in Massachusetts, or “disruptive innovations” that are simpler, less costly, and more convenient to use. These are all terribly important, and their full potentials will, no doubt, require data-based innovations.

Two Elephants and Six Blind Men

The elephant in the living room is what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.

David Brailer, MD, February 15, 2005, as quoted in The New York Times by Steve Lohr, “Health Industry under Pressure to Computerize”

Our health care system is as huge and cumbersome as an elephant, and all the players — like the blind men in the story — see the elephant differently. Doctors holding the tail perceive the system as constraining as a rope, purchasers touching the leg find it as immovable as a tree, and plans holding the trunk see it as devious and unmanageable as a snake.

We're blind to the system's true shape, and what we can't see is killing us. It's also crushing us financially, but we can't move it — can't fix it — until we can see it. The system is opaque, abstruse, variable, incredibly complex, and weirdly fragmented. Its very nature makes vision of the whole impossible, say experts.

Martin Sipkoff, “Can Transparency Save Health Care? “Managed Care Magazine, 2004

Just over two years ago, David Brailer, MD, then national health information coordinator for the U.S. Department of Health and Human Services, commented small practices were the “The Elephant in the Room.”

He meant that unless small practices adopted electronic health records, the government’s plan to establish an interoperable computer system linking all U.S. health system components might fail.

At the time Brailer made his remarks, among groups of 50 or more physicians, two thirds (68%) had adopted electronic health records. For groups of five or fewer, only 12% had EHRs, and among solo doctors or doctors in groups of two, only 1% had such records. Yet these small groups of five or less made up half of practicing physicians in the U.S.

Past and Present

I was reflecting back on the “Elephant in the Room” when I ran across this paragraph in the “In Brief” section of the March 19, 2007, issue of the American Medical News.

A survey by the consulting giant Accenture finds that two-thirds of patients say the use of electronic medical records is an important factor in choosing a physician – and half say they would pay a “reasonable” extra fee to see a physician who uses them. Meanwhile the same survey found 11% of physicians using EMRs. Accenture surveyed 600 patients and 100 doctors.

Apparently, independent patients and independent doctors don’t always see eye-to- eye.

Independent Patients

Meanwhile I came upon this paragraph in the March 15 Online Wall Street Journal in article bearing the title “Many Americans Disregard Doctors’ Course of Treatment”.

A quarter of America’s patients have a drug prescription unfilled because they felt it was unneeded and a fifth obtained a second opinion because they felt their doctors recommendations were too aggressive

The Wall Street Journal piece brought to mind to report by the Boston Consulting Group in 2003 Finding a Cure for Unfilled Prescriptions and Missed Drugs.

Briefly that report indicated 33% of patients took drugs less often than prescribed, 25% said they delayed taking the drug, 20% stopped taking the drug because of perceived side-effects, 17% said the drugs were too costly, and 14% believed they didn’t need the drug,

They viewed themselves, not their doctor, as the ultimate judge of what drugs they need. Fully 24% said “forgetfulness” had nothing to do with their failing to comply (italics mine). Apparently independent patients felt perfectly capable of making judgments about their own care, regardless of what their doctors said.

In the same time frame, a March 16 piece of mine (not to be confused with piece of mind) appeared in Healthleadersmedia.com news, "Pay for Performance and Quality Outcomes: Buzz, Metrics, and Human Nature." I said patients often act independently when outside the doctors immediate sphere of influence. Consequently, I reasoned, pay for performance for clinical outcomes in the outpatient arena wasn’t likely to cut costs or improve long term outcomes. Americans’ penchant for individualism and deciding for themselves what was best for their health isn’t necessarily good for their health.

Dispersed Care by Multiple Practitioners

Meanwhile, the March 15 edition of New England Journal of Medicine contained an article “Care Patterns in Medicare and Their Implications for Pay for Performance” by a group from the Center for Studying Health Care Change in Washington, D.C,, and an editorial “Paying for Care Episodes and Care Coordination” by Karen Davis, PhD, head of the Commonwealth Fund in New York City.

Here are the results and conclusions the group from the Center for Studying Health Care Change reached after studying 1.79 million fee-for-service Medicare beneficiaries.

Results: Beneficiaries saw a median of two primary care physicians and five specialists working in four different practices. A median of 35% of beneficiaries' visits each year were with their assigned physicians; for 33% of beneficiaries, the assigned physician changed from one year to another. On the basis of all visits to any physician, a primary care physician's assigned patients accounted for a median of 39% of the physician's Medicare patients and 62% of Medicare visits. For medical specialists, the respective percentages were 6% and 10%. On the basis of visits to primary care physicians only, 79% of beneficiaries could be assigned to a physician, and a median of 31% of beneficiaries' visits were with that assigned primary care physician.

Conclusions: In fee-for-service Medicare, the dispersion of patients' care among multiple physicians will limit the effectiveness of pay-for-performance initiatives that rely on a single retrospective method of assigning responsibility for patient care.

An Elephant Poem

These results and conclusions, showing that patients, acting independently, often chose multiple physicians from whom to receive care, led me to look up the poem by John Saxe (1816-1887) on an Indian legend of six blind men who felt different parts of an elephant’s anatomy.

I‘ve modified the poem for this essay’s purposes. Think of the six blind men as various health system fix-it gurus, each in their own way seeking Nirvana, and the elephant as a conglomeration of interacting independent doctors in small fee-for-service practices and their independent patients, the combined mass of which comprise our health system’s bulk.

The Six Blind Men of Nirvanastan and the Health Care Elephant

There was six men of Nirvanastan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind),
That each by observation
Might satisfy his mind.

The First, A Universal Coverage Sage,
approach'd the Elephant
And happening to fall
Against his broad and sturdy side,
At once began to bawl:
"God bless me! but the Elephant
Is very like a wall!"

“The sage roared, it’s clear what all we need to do.
It’s my comprehensive compassionate moral view,
That we put all inside and behind a common wall,
For this, everyone will be held in absolute thrall.”

The Second, A Market-Medicine Man,
feeling of the tusk,
Cried, -"Ho! what have we here
So very round and smooth and sharp?
To me 'tis mighty clear,
This wonder of an elephant
Is very like a spear!"

“It’s obvious to me what must be done,
Make all patients consumers to be won,
When they seek lower prices at the spear of care.
Price shopping will make care fair and square.”

The Third, An Ivory Tower Elitist,
approach'd the animal,
And happening to take
The squirming trunk within his hands,
Thus boldly up and spake:
"I see," -quoth he- "the Elephant
Is very like a snake!"

“Hence, spake the elitist, we must end greed,
It’s clear government price controls we need,
All physicians are nothing but slithering snakes,
We simply must control the money each makes.”

The Fourth, A Consummate Capitalist,
reached out an eager hand,
And felt about the knee:
"What most this wondrous beast is like
Is mighty plain," -quoth he,-
"'Tis clear enough the Elephant
Is very like a tree!"

“Consider this huge tree’s branching side,
Health care’s an economic engine we must ride,
It accounts for one-fifth of our huge economy,
Let patients and doctors have their autonomy.”

The Fifth, A Savvy Systems Savant,
who chanced to touch the ear,
Said- "E'en the blindest man
Can tell what this resembles most;
Deny the fact who can,
This marvel of an Elephant
Is very like a fan!"

“Said he, simply fan out and apply statistics,
Manage, measure, and do the basic heuristics,
It comes down to total systems engineering.
Which will make variables go disappearing.”

The Sixth, A Practicing Pragmatist,
no sooner had begun
About the beast to grope,
Then, seizing on the swinging tail
That fell within his scope,
"I see," -quoth he,- "the Elephant
Is very like a rope!"

“Look, stop thinking in terms of some overall system,
Requiring patients and their doctors to act in tandem.
As individualists, give each of them some rope,
Each by themselves in their own way will cope.”

And so these men of Nirvanastan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right,
And all were in the wrong!

So, oft in philosophic wars
The disputants, I ween,
Rail on in utter ignorance
Of what each other mean;
And prate about an Elephant
Not one of them has seen!

Concluding Remarks

Many management and policy experts purporting to have answers to U.S. health system woes have never been inside a busy solo or small practice primary physician’s office for a day. Nor have many ventured inside the minds of independent American consumers who frequent small practices.

Consumers want the best of all possible worlds – a close personal relationship with their doctor, access to the latest in life-saving and function-restoring technologies, individual freedom with unlimited choice, high value, and low prices; and financial security – a wonderful combination in Nirvana. Physicians, by and large, want the freedom to make their own clinical judgements based on their knowledge of the patietn.

Blind experts feeling different parts of the elephant tend to think they can manage and coordinate various parts of system into one coordinated, functioning, interrelated elephantine whole.

These experts talk of imposing outside solutions, varying from: universal government-run coverage, across-the-board pay for performance, herding hordes of physicians out of fee-for-service into salaried employment inside integrated health systems, coordinating care by using patient health records and electronic health records, lumping all individual payments into bundled payments for episodes of care, assigning all patients to one single primary care quarterback, shifting costs to consumers so they will take responsibility for health and shop for the best care in one huge health care marketplace; and, of course, achieving the Mother of Nirvana Dreams – total transparency.

These management and policy experts are each partly right and partly wrong, but they often neglect patient behavioral and choice sides of the patient-doctor equation, and desire of patients to be ultimate and independent judges of their own medical care – drugs they will take, physicians they will see, and personal functional outcomes they seek.

These purblind pundits may also overestimate the power of economic incentives compelling independent doctors to join virtual or centralized integrated systems for the common and organizational good.

I don’t mean to rain on the parade of these well-intentioned experts. Many of their ideas work well under the right circumstances in certain organizations and in certain parts of this vast continental nation. But, short of massive protests in the streets filled with righteous indignation over the 47 million uninsured, or a natural disaster, a World War, or a global recession, I doubt if universal coverage, and its stepchild, or universal coordination will come soon.

Desire for independence, choice, and personal self-regulation are powerful ingredients in America’s cultural soul. Even in the face of oft-heard protests that the “system” is “broken” and needs to be “fixed,” most Americans seem to prefer a multi-payer pluralistic system – a system allowing individualism and choice among various participants.

For the near future, I expect America to continue to have a blended mix of federal, public, and private subsystems – each with its special demands, each requiring different skills and management, and each having different elephants in examining rooms.

Ed Roberts, MD, The Doctor Who Gave Bill Gates III His Start

It was the Altair 8800, on the January 1975 cover of Popular Electronics, that really set off the (personal computer) boom. A company called MITS, in Albuquerque, sold the Altair for $395 as a kit and $495 assembled. Within three months 4,000 people had ordered it.

Landmarks in Digital Computing: A Smithsonian Pictorial History, 2007

I see by the March 8, 2007 Forbes Magazine that Bill Gates III, 52, founder of Microsoft, is the world’s man for the seventh year in a row with a net worth of $56 billion.

Contrast this with the economic lot of Ed Roberts, MD, a 65 year old solo internist in Cochran, Georgia, who is struggling to keep his practice going because of low Medicare and Medicaid reimbursements.

Cochran is a rural community with a population of 4,455 – 55% white and 42% black-- with a high rate of Medicare and Medicaid patients and a below average annual income of $24,000. Cochran is 120 miles southwest of Atlanta and 37 miles from Macon.

Robert’s financial situation is ironic because he's the person who gave Bill Gates his start in 1975. Roberts, then an electrical engineer, developed one of the first personal computers, the Altair 8800, which was the prototype that Bill Gates and his fellow Harvard drop-out, Paul Allen, 54, now #19 on the list of the world’s top billionaires with a net worth of $18 billion, adopted to start the Microsoft empire.

The economic contrast between these two billionaires and Dr. Roberts reminds me of a personal experience. Several years back, I was invited to give a talk in Seattle. I was told by a struggling Seattle primary care physician that Microsoft employees were driving German and Japanese luxary cars, while the doctors were driving American economy cars.

You’d think Roberts' medical office would be filled with computers, the latest medical software, digital assistants and other hightech gadgets. After all, 32 years ago, Roberts helped develop one of the world's first personal computers, the Alstair 8800. Roberts turned medical doctor in 1986, the year he graduated from Mercer University Medical School in 1986. He did his internal medicine residency there. He ended up in Cochran, where, he observes, "I wanted to make a difference."

The truth is Roberts now spends very little time working with computers. That's because time is precious for this doctor who says he's too busy to devote much time to computers. He records patient records on a computer, but beyond that doesn’t fuss much with computers and doesn’t have any fancy electronic health record system.

And he says he's not convinced that existing software with its awkward, often irrelevant, features will make his practice operate more efficiently.

"One of the mistakes being made right now is that software is being written with the idea that everything has to be on the computer." Roberts says. "You don't work that way, you are not taught to think that way, and it is a cumbersome way to go."

Such comments may be common for physicians reluctant to dive into the digital age. But for a man whose expertise spans the sciences of both electronics and medicine, it comes as a surprise.

The Road Roberts Traveled

Today, Roberts, 65, is an internist serving Cochrane, Georgia., a small rural town. That's a long way from where he was in the late 1960s and early 1970s working as an electrical engineer in Albuquerque, New Mexixo.

Assigned to a weapons lab with the U.S. Air Force after he graduated college at Oklahoma State University, Roberts was in Albuquerque when he formed his first company, Micro Instrumentation Telementry Systems (MITS).

"We built telemetry equipment for rockets. That was in 1968 and 1969. We didn't do too well because there was not much demand for our product, but we learned a lot about setting up a company and marketing," Roberts recalls.

"By that time, the large scale and medium scale integrated circuits were becoming available. And I became intrigued about building a calculator. But my partners said there was no market for home calculators, so we parted company and I bought them out. Before I got into the calculator business, large-scale integrated circuits became available. And I built the first large-scale calculator for the market."

Known as the MH 16 Calculator, it wasn't anything like the slim, pocket-sized calculators available today. It was about as big as a sheet of paper and sold as a kit for about $170.

From the calculator, sprang for the idea of creating a home computer. So Roberts and his company developed the Altair 8800, a breadbox-sized contraption that also sold in a kit and was one of the first computers designed for personal use.

An article on the Altair 8800 appeared in Popular Electronics magazine in January 1975.

"Project Breakthrough!" read the magazine cover's bold red headline. "World's First Minicomputer Kit to Rival Commercial Models ... 'Altair 8800"'

Overwhelming Response

The response was overwhelming. Computer buffs began calling MITS to find out more about the computer and how it worked. One call came from two Harvard undergraduates who saw the article and got excited: Bill Gates and Paul Allen.

"We were getting ten calls a day from other software people, as well. It became difficult to distinguish. who was real and who wasn't," Roberts recalls. At the time, the company was searching for programs and software to run on the Altair 8800.
"I made the decision that the software had to be in BASIC programming language. And the first person to show up in Albuquerque with a workable BASIC program would have the contract," Roberts says. "There were probably thirty or forty people who were candidates. Paul Allen called and said he had a system he wanted to demo. That was the spring of 1975."

Allen quickly arrived in New Mexico, ready to show off his BASIC software to Roberts and the MITS staff.

"I picked him up at the airport. He was maybe 21. I took him to the hotel in Albuquerque, and he said he didn't have any money to pay the hotel bill so I gave him my credit card so he could stay in the hotel that night," Roberts says.
"The next day, we loaded up his software, but then it crashed. Paul knew what the problem was, so he called Bill (Gates) and they cut a new tape. They sent it out airfreight, and we loaded it and it played. It had a lot of bugs in it, but for a brand new piece of software that had been developed without ever seeing the Altair, it worked, and I was impressed.

"What those guys had done, instead of the usual approach, which was brute force design of software, they had taken the time to design an emulator.

...They had the power to simulate the Altair system. That's the standard way things are done now, but it was unprecedented then, and that was the genius of what they did."

Roberts liked what he saw with Allen and Gates, so they set up shop at MITS and wrote the BASIC programming for the Altair.

What's Roberts' view of Gates, the multi-billionaire who heads Microsoft today?

"Bill is an extremely bright guy, but as far as his technical ability, he isn't unique and that's not why he is where he is," Roberts says. "He has enormous business skills. He has a genius for business, and he would not like to admit this, but luck was a big part of his great success.

To his credit, Roberts displays no resentment or jealousy of Gates’ and Allen’s financial success. “I still touch base with them from time to time,” he says. Roberts is philosophical. He muses, “They saw what they had to do, and they did it.” Which sounds a bit like the Chinese proverb, “To know and not to do is not to know.” Or it smakes of that quote from Napolean Hill in his 1937 motivational classic, Think and Grow Rich! “What the mind can conceive and believe in, the mind can achieve.”

Two Morals Followed by Two Questions

This tale has two morals:

1) Fortunes go to those who sell the world, not to those who concieve the first idea or who develop the first product. The reality is that it takes business smarts and a management team to market an innovative concept to a wider world.

2) Life isn’t necessarily fair for primary care physicians who work in the clinical trenches in rural regions seeing 30 or more Medicare and Medicaid or uninsured patients each day in low income populations.

A 2006 Merritt Hawkins and Associates survey of 285 medical graduating medical residents indicated none (0%) would choose to practice in a community of 10,000 or less.

The two questions are:

Who will replace the Dr. Ed Roberts of rural America?

Who will care for the rural sick?

Who Should Health Care Consumer Trust?

Friedrich Hayek, 1974 Nobel Laureate in economics, won his prize by arguing self-organizing free-market capitalism is the best system for governing.

Centralized government agencies like Medicare, Hayek believed, simply didn’t and couldn’t know enough about patient-doctor relationships to regulate on the ground transactions. Attractive as centralized planning sounds on paper, and as seductive as it is for providing financial security, Hayek maintained government simply wouldn’t and couldn’t work in health care marketplaces. Hayek concluded a policy for freedom of individual patients and physicians “is the only truly progressive policy.”

Wall Street Journal OP-ED Article

Which brings me to Wall Street Journal OP-ED piece by Scott Gottlieb, MD, deputy commissioner of the FDA from 2005 to 2007, now a resident fellow at the American Enterprise Institute.

Gottlieb asserts government health agencies don’t trust doctors to choose the right drugs for their patients, or for that matter, for patients to decide what drugs are right for them (“Prescription for Trouble,” The Wall Street Journal, March 6, 2007).

Here are Gottlieb’s words:

Inside the federal agencies that oversee parts of the health-care system, there is a palpable view that doctors can no longer be trusted to do the right thing.

The Food and Drug Administration, Medicare and even the Justice Department all believe they cannot rely on many doctors to heed safety warnings, wisely weigh new medical information, or follow therapeutic approaches that maximize health benefits or lower health benefits.

Reflecting this pervasive distrust of medical practitioners, Medicare is increasingly tying payments to choices doctors make, compensating doctors more to follow certain cookie-cutter treatments or practice guidelines that are promoted by the agency because they are believed by government experts to maximize benefits and reduce health-care costs.

Who to Trust?

So who can you trust, your government or your doctor?

Here are your choices,

• Government experts holding forth in bureaucratic cathedrals in Washington, D.C., issuing position papers and perusing data output sheets, far removed from clinical medicine.
• Local medical practitioners seeing patients every day in the clinical trenches at ground zero.
• Some outside source, which can increasingly be found on the Internet
• Yourself.

Gottlieb’s Answer

Gottlieb’s answer is that Medicare treatment guidelines, issued from on high inside the Beltway, are not the right answer for everyone “because there is a need for judgment that attunes treatments to individual variations and preferences.”

Direct regulation will not, Gottlieb says, fix anything but will sacrifice medical autonomy and patient choices, a medical stew with so many permutations and combinations that no one, least of all government “experts,” know what’s going on or foresee consequences of regulating health consumer/doctor interactions. Gottlieb favors physician organizations, working in concert with government, to develop guidelines.

What to Do?

So what’s a health consumer to do?

In the first place, don’t dismiss government out of hand. Trust the government’s judgment on certain drugs with huge databases covering hundreds of thousands of patients. Government is more likely to pick up evidence of untoward effects of a few recently released drugs than a single doctor, seeing a mere handful of patients. Vioxx-induced heart attacks are an example. Another may be the latest FDA warning that erythropoietin, or Procrit, may cause heart attacks if given in too high a dose.

Still government can’t regulate every transaction or predict every complication in every patient, even if it issues thousands of regulations and guidelines in hundreds of manuals.

Personally I trust my doctor in most situations. I know him. He knows me. And he is doing the best he can under sometimes difficult circumstances, including government interventions into clinical situations for which it knows nothing but statistics. People may not be reflected in overall statistics; people are variable individuals. The live and die as individuals, not as statistics.

Go Directly to Revolutionhealth.com

Or you can proceed directly to revolutionhealth.com. Steve Case, who founded American Online, has moved on to found another company, the Revolution Health Group. He and his management team has assembled a group of expert specialists to answer your questions. Go to revolutionhealth.com, and its home page will come up. On the left hand side of that page, you will see a green box with the heading, ”How can we help you?” The box contains this list.

• Compare and rate doctors and hospitals
• Learn about a condition
• Discover tips to lead a healthier life
• Find drugs and treatment options
• Check a symptom
• Get support and exchange insights
• Learn about our membership programs

Click on “Get support and exchange insights,” and you can read blogs of specialists, or you can post a topic or question that personally concerns you. You can pick from 45 topics or questions arranged alphabetically, and, depending on which one you choose, you will be directed towards a specialist whose opinion you can trust.

In The End, Trust Yourself

In the end, trust may come down to trusting your own judgment. There are no easy answers. In other words, sometimes you must trust yourself rather than the government or your doctor.

• You can ask your doctor if you really need this drug, e.g. antibiotics for “bronchitis” or a viral disease.
• You can go to a website like healthgrades.com to check the credentials of your doctor (It will cost you $7.50).
• You can check around the community to see what neighbors and others think of your doctor.
• You can go to a respected health facility, or a group practice, within your community, which generally plays by the regulatory rules.
• You can go to google.com to see what the side effects of a drug are.
• You can take a list of your current medications to your local pharmacist to see if any potential drug interactions might be.

My Bias

My bias is towards a trusting personal relationship with your doctor. He or she is more likely to know your history, your condition, and your family than any faceless bureaucrat in Washington, even with the best of intentions and the best of statistics.

My bias is towards a open-ended partnership with your doctor, who is willing to answer your questions candidly and to direct you towards reliable Internet sources. My bias is towards autonomous physicians, rather than physician automatons blindly following Medicare guidelines.

In free-market capitalistic system like the United States, trust holds us all together. Trust makes a market-based system work. This trust is important in health care. For better or worse, we’re all in this together.

In the story of the hedgehog and the fox, the fox knows many things and hedgehog knows one thing. I’m a hedgehog. I believe in a free-market capitalistic society, trust lifts all boats. With the help of savvy consumers, leaks will be plugged. Government may pug some leaks, but not many, and it can’t plug all leaks. It’s too far removed from care sites and can’t foresee, much less manage, all variables.

On Blogging and the Self Escaping into the Open

Early each morning I have a ritual.

• I enter my daily blog,
• check my email,
• down a cup of coffee,
• read the health care news in the Wall Street Journal and the New York Times, • turn to healthleadersmedia.com – the reigning queen of health news aggregation and analysis web sites.

On occasion, I visit the websites of two rival health news sites -- fiercehealthcare.com, “the healthcare industry’s daily monitor,” and AIShealth.com, “specialized business information for health care managers.”

Healthleadersmedia.com Site

Each week day the healthleaders site displays feature news stories. Today, March 16, I glom onto the site because my article “Pay for Performance and Quality Outcomes: Buzz, Metrics, and Human Nature” made its maiden appearance as the lead story. Bringing attention to my Healthleaders piece isn’t why I blog today. I blog because a Healthleaders newspaper story this day from The Detroit Free Press, dated March 14, is entitled “ Is Doctor Blogging Too Much of a Risk?”

Do Doctors Blog Too Much?

The Detroit Free Press news piece tells of doctors who may divulge too much about patients, including graphic and gruesome clinical details. Critics fear doctor bloggers may be breaking rules of confidentiality and tenets of HIPPA (Health Insurance Portability and Privacy Act)– that aptly named government generated bureaucratic hippopatmus designed to protect patient privacy.

No Blogging Ground Rules

The news story goes on to say no blogging ground rules exist for what’s acceptable. It quotes a neonatologist, now getting 800 hits a day after saying,

“I don’t mind it so much when a young single woman comes in with her first pregnancy because anyone can make a mistake. But when the young woman gets pregnant repeatedly, time after time, she degrades herself and her children, condemning herself and them to a life of dependency and irresponsibility.”

Offending Some, Pleasing Others

Although the neonatologist blogger didn’t reveal names or further clinical details, his message offended some, including secular progressives who believe anything and everything goes, and blogs are no place to cast moral judgments. Other observers said they saw no evidence doctor bloggers were breaking moral codes or violating HIPPA rules, or saying things out of school that should not be said.

One doctor-blogger-friendly soul commented,

“People forget doctors are people. There’s a tendency to think they’re either God or people who just want to shove pills down your throat. When you’re in their blogs, you see they’re real people. Also, in these blogs, comments are open. If you have a concern, you can easily leave a comment. It’s a wonderful way for patients to have access to doctors.”

Blogs as Springboards for Physician Creativity

Blogs are also great springboards for unleashing physician creativity – for revealing latent gut feelings about the real world behind those white coats. Physician blogs sometimes remind me of this passage from The Elements of Style by William Strunk and E.B. White (second edition, McMillan Publishing Company, 1972)

The mind travels faster than the pen. Consequently, writing becomes a question of learning to take occasional wing shots , bringing down the bird of thought as it flashes by. A writer is a gunner, sometimes waiting in his blind for something to come in, sometimes roaming the countryside to scare something up.”

That’s a good definition for medical blogging, in essence a form of health care gunning.

White proceeds to take this wing shot.

Every writer, by the way he uses the language, reveals something of his spirit, his habits, his capacities, his bias. This is inevitable as well as enjoyable. All writing is communication, creative writing is communication through revelation – it is the Self escaping out into the open. No writer can remain long incognito.

The Inevitable Concluding Verse

The last quote leads inevitably to this perverse verse:

There once was a prolific medical blogger named Al Frito,
Who tried methodically and doggedly to remain incognito.
He fought to conceal his inherent bias.
He sought to reveal himself as pious.
But try as he may, in his blog, his basic bias
he could not pocket veto.

Doctor-Led Search Engine Innovations

“Attempt the end, and never stand to doubt,
Nothing’s so hard but search will find it out.

Robert Herrick 1591-1674
Seek and Find

When we speak of Internet influence on modern society and culture, we speak of ubiquity, instantaneity, and availability of information anywhere, everywhere, anytime. We speak of shrinking and irrelevancy of distance. We speak of universal transparency. We speak of individuality run amuck. We speak of universal expression of deeply felt emotions. We speak of blogging, media’s new frontier. We speak of a world powered by cyber-based search engines.

We speak of chaos, confusion, and complexity. In health care, physicians are pivotal in developing relevant, useful, and impactful clinical search engines. These new engines bring order to bear on seemingly intractable problems and put critical information at the fingertips at those responsible for cost and effectiveness of care when that information is most needed, when the patient is in the room and when the receptionist announced, “The doctor will see you now.”

Several years back a friend served as CEO of a doctor-founded search engine company. The company developed software for collecting and downloading clinical research from around the globe, and then, for a fee, within 24 hours of the research’s publication, bringing it topracticing doctors' fingertips at the click of a mouse.

This start-up failed, as most start-ups do, from multiple reasons, including inability to raise money, assemble a harmonious management team, lack of physician enthusiasm on the receiving end, and bad timing.

As every start-up entrepreneur knows, timing is everything. Now, for my friend, the timing might be right. It is never too late to innovate. It seems everybody is rushing into the search engine field – Kaiser Permanente, MedAI, Aetna, health plans of every ilk, WebMD, Revolution Health, Healthline, and now Microsoft – using and deploying such tools as data mining, predictive modeling, consumer monitoring, episode data aggregation, and customer relationship handling.

On February 27, Microsoft announced it was buying Medstory, Inc, a small startup founded by Alain Rappoport, MD, PhD, in 2000 in Foster City, California. The Medstory acquisition follows Microsoft’s purchase last year of Azyxii, Inc., a clinic software company displaying information form scanned documents, x-rays, MRI and CT scans, and ultrasound images. As an aside, I believe image transfer may monumentally transform medical practices. It is much easier to scan a document or image than to enter it digitally.

Medstory applies artificial intelligence techniques to medical and health information gleaned from medical journals, government documents, and the Internet.

Microsoft says it bought the company to improve the consumer experience in health care. The biggest story here is that Microsoft has decided to become a dominant player in the health care search engine field.

The two Microsoft acquisition were preceded by Aetna’s 2005 acquisition of ActiveHealth Management, Inc, founded by Lonny Reisman, MD, a New York City internist. Founded in 1998, ActiveHealth Management provides clinical decision support to physicians and members on an individualized basis and health care data analytics tools that enable customers to analyze the health care of their entire covered membership.

Clearly big innovations are afoot in the search engine and medical intelligence field. Kaiser believes, for example, that it is possible to use its Archimedes Project technologies to run clinical trials for patients without use of human subjects. In Kaiser’s case, the genius behind the scene is a doctor named Doctor David Eddy, who also has at PhD in mathematics.

Many search engine company founders are MDs. This should come as no surprise, since physicians know what other physicians need and what patients want.

Alain Rappaport, MD, founded Medstory. Medstory, he says, increases the efficiency of health care industry processes, from drug development to personalized medicine. Rappaport was previously (1985-1996) co-founder, President, and Chief Scientist of Neuron Data, Inc., a world leading company in artificial intelligence and other business-critical software components. He is currently Adjunct Faculty in the School of Computer Science and Robotics Institute, Carnegie Mellon University. From 1997-1999, he held an appointment as Senior Advisor, Office of the Director, Center of Excellence for Information Technology, National Aeronautics and Space Administration. He is a founding member of the Innovative Applications of Artificial Intelligence (IAAI) Conference.

Another physician leader who founded a search engine firm is Lonny Reisman, MD, who founded ActiveHealth Management in 1998, and which Aetna acquired in 2005. ActiveHealth Management’ products and services are designed to improve clinical care and outcomes and reduce medical costs. The system continually compares this patient data to the latest evidence-based medicine and standards of care, to identify treatment opportunities for those most at risk. These opportunities or suggestions - called Care Considerations - are then communicated to the treating physician and/or patient with the goal of improving the patient’s health.

Search Engine Drivers

One driver here is consumer-focused health care. The notion is that with shifts in demographics, economics, technology, and policy, more individuals will desire, or be forced to make decisions on treatment and provider-selection on their own. Aging baby boomers, used to having things their way, will want personal choice, and a strong say in how they’re treated. Besides, according to a study last year by the Pew Internet and American Project, eight million people every day search for health care information.

There’s another driving-factor as well: competition for the health engine dollar. Microsoft is going head-to-head with WebMD which has just announced a quarterly profit of $8.9 million on $80.6 million of revenue. Steve Case, who founded AOL, is said to have put up $500 million of his own money, though Case disputes this figure and puts it closer to $100 million, to back Revolution Health, hoping to use its website to empower consumers to take charge of their health care and its costs.

The Internet search engine frenzy reminds me of the child's verse about the Merry-Go-Round, “Faster and faster she goes, Where she stops, no one knows.”

Where Have All the Flowers Gone?

In Defense of Doctors, the Department of Defense, The U.S. Army Medical Corps, and The Veterans Administration

Where have all the flowers gone? Long time passing.
Where have all the flowers gone? Long time ago.
Where have all the flowers gone?
Young girls picked the , every one.
Oh, when will they ever learn?
Oh, when will they ever learn?

Where Have the Flowers Gone?
Words and Lyrics by Pete Seeger, 1961

Flowers come in all sizes, many colors, in varying seasons, and with unique, changing, and complex characteristics. There are glorious and anemic ones, bold and shy ones, adventuresome and retiring ones. All differ. Roses may be red, and violets may be blue, but dandelions get around more than the others do.

Whatever their characteristics, flowers symbolize hope, optimism, renewal, beauty, and life. On the wall of my office hangs a plaque. The plaque proclaims,” Don’t worry, don’t hurry, and don’t forget to smell the flowers.” I don’t forget, for flowers are what it’s all about.

We reward deeds well done with flowers. What do you give a diva to show how much you appreciate her aria? How do you tell people you care for them? With flowers, of course. I recall a sage old Connecticut family practitioners. When asked why he and his wife of fifty years had hit it off so well, he confessed, ”I send her flowers every Saturday to celebrate another week.”

Where have all the flowers gone in our society? Why don’t we send flowers anymore?

This is an anti-hero age. We no longer send bouquets or offer praise or optimism, beauty, life, or achievements.

Instead we doubt, dissect, disparage, analyze, impugn, question, and investigate.

Boy, do we investigate. We investigate Presidents, Vice-Presidents, Attorney Generals, Politicians, Army Generals, Priests, Physicians, and Establishment Institutions. The prevailing attitude is: if they or it have succeeded in our society, something must be wrong. Our most prominent heroes, even Mohammad Ali, have feet of Clay. So we send no flowers, only regrets that things are not perfect.

“Investigative” reporters “reveal” to us what we know already – that our leaders and the organizations they lead suffer from human frailties. The reporters “astonish” us each morning with mundane disclosures: Presidents dislike their political enemies. Partisan politics exists. Our enemies are bent on killing us – and it’s our own fault because we do not talk to them. Congressmen appease, and even try to please, their constituents. Supreme Court Justices, heaven forbid, argue among themselves over controversial issues. The Justices even maneuver in their cloakrooms to win over their brethren to their point of view. Goodness, learned lawyers act like they are made of flesh and blood. No flowers are bestowed upon them for lifetimes of hard work and solid accomplishments.

And physicians?

Well, they are the worst. Imagine. They err like other mortals. They occasionally misinterpret signs, symptoms, and results. They cannot guarantee perfect results under all circumstances. They cannot even repeal the Laws of Nature, or the inevitable Limits of Longevity. Physicians are not even omnipotent, omniscient, or omnipresent.

Take those Army doctors at Walter Reed or VA physicians everywhere. Can you believe it? They didn’t inspect all those moldy dormitories housing wounded veterans, and they did not respond immediately to all those complaints filtering up through the military medical bureaucracy, the largest medical-hospital complex in the world.

Sure, these military and VA doctors are saving more soldiers on the frontlines than in any other previous war. Sure, they have installed a universal electronic health record system linking all their hospital and physicians – a system that allows them to outperform the civilian sector for most quality indicators and is looked upon with wonderment by medical managers and medical executives. Sure, veterans are flocking to VA hospitals and clinics, for those $7 prescriptions Sure, the VA has launched a construction project called CARES. Sure, most military hospitals are fifty years old, compared to 12 year old in the civilian sector. Sure, heads had to roll, even heads that have devoted all of their lives to there military careers and their country.

And those civilian doctors? Reporters are stripping their petals one by one, complaining they are “too conservative,” or they don’t spend enough time with patients, or make too much money. They are too highly paid, the argument goes. Forget that average $100,000 medical education debt. Why should should complain? Sure, their incomes have not kept pace with inflation for a decade. Sure, the amount doctors are paid has dropped for the third year in a row and represents only 6% of all the money spent on health care in 2006. Sure, physicians are expected to receive significant cuts under Medicare’s pay formula for the next decade. Sure, managed care and Medicare forces doctors to spend only 15 minutes with patients in order to meet their bottom lines. Sure, the doctor shortage and economic squeeze leaves little time to answer patients’ questions. Sure, they are producing all medical innovations, new drugs, and new treatments that are lengthening longevity and making us functional into old ages. But medicine costs too much, and somebody has to sacrifice.

Maybe we should praise our doctors and their institutions, considered many to be “the best in the world.” That may be why the U.S. introduces 80% of the world medical innovations and wins 80% of the world’s Nobel Laureates in Medicine even though we only have 5% of the world’s doctors. Maybe we should give our doctors flowers, instead of defoliating them. Maybe they should be our heroes, rather than our villains. American doctors are not miracle workers, but given limited resources and Nature’s limitations, they are damn good.

Be fair. Put physician performance in perspective.

Smell the flowers. Show flower power. Plant a flower. Grant your favorite gastroenterologist a GI Bill of Right. Give Decorations to those who treat patients.

And remember. Those who throw dirt lose ground.

Criticism has its place. But so do flowers.

(In the interest of full disclosure, I am not a veteran. I do not have children or relatives in the Armed Forces. I do not receive pay from the VA. I did do part of my training at a VA hospital, as do more than half of American physicians.)

References

1. Brianigan, William, Dole, Shalala Pledge Full Investigation into Military Care, Washington Post, March 8, 2007.
2. Shanker, Thom, and Stout David, Chief Army Medical Officer is Ousted, New York Times, March 13, 2007.
3. 2008 Dems Vow to Reform Veteran Care, Associated Press, March 15, 2007.
4. Glendinning, Glen, Medicare Ripple Effect Linked to Dip in Spending Growth on Doctor Services, American Medical News, March 12, 2007.
5. Adams, Damon, Tight Schedules at Odds with Patient Demands, American Medical News, March 12, 2007.

On Physiatrists and Wiping The Egg Off My Face

This is my 90th blog in 90 days, which must be a world record for bloggorhea. Unfortunately, when you write a blog each day, you may occasionally commit a sin of omission. Yesterday morning, when I posted “On Physical Therapists and Keeping Patients Moving,“I committed a whopper.

In speaking of physical therapists, I failed to mention physiatry, the long established and respected medical specialty defined as follows by the American Academy of Physical Medicine and Rehabilitation:

A physiatrist is a physician specializing in physical medicine and rehabilitation. Physiatrists treat a wide range of problems from sore shoulders to spinal cord injuries. They see patients in all age groups and treat problems that touch upon all the major systems in the body. These specialists focus on restoring function to people.

To become a physiatrist, individuals must successfully complete four years of graduate medical education and four additional years of postdoctoral residency training. Residency training includes one year spent developing fundamental clinical skills and three additional years of training in the full scope of the specialty.

There are 79 accredited residency programs in physical medicine and rehabilitation in the United States. Many physiatrists choose to pursue additional advanced degrees (MS, PhD) or complete fellowship training in a specific area of the specialty. Fellowships are available for specialized study in such areas as musculoskeletal rehabilitation, pediatrics, traumatic brain injury, spinal cord injury, and sports medicine.

My Oversight Corrected

My physiatrist readers quickly corrected my oversight.

• First, my good friend, Val Jones, MD, senior medical director of the portal for the Revolution Health Group, and a fellow blogger (ValJonesMD’s blog: The Voice of Reason) weighed in with this observation.

Thanks for your nice blog post about the importance of movement to good health. I must tell you, though, that I was disappointed by the lack of even a mention of Physiatrists (my specialty)… it’s kind of like talking about how great the field of pathology is because of lab technicians, but not mentioning the pathologist.

I have meant for a long time to write a post about “What the heck is a Rehab Doctor?” and now you have galvanized me into action.

It is so sad that my specialty has the poorest PR efforts known to medicine. It is rare for anyone to know who we are or what we do, though we labor on… caring for the poor and unwanted (those disabled by stroke, spinal cord injury, cerebral palsy, amputations and the like), doing what we can to improve life through movement and generally non-invasive therapies.

To me, physiatry IS the original integrative medicine. These Bastyr types like to take all the credit, but we PM&R docs have known since the turn of the century that rehabilitating people takes a masterful mix of art and science.

I’ll create a post today or tomorrow about this… so stay tuned.”

My comment: Val really stung me with her comment about pathologists. We pathologists tend to be the Rodney Dangerfields – the Digger O'Dells - of medicine. We get no respect from the public. Once I mentioned to a society matron I was a pathologist. After a second’s hesitation, she remarked, “Oh, did your mother have any children who lived?” Physiatrists may experience similar problems connecting with the public. Because of similarly sounding names, physiatrists may be confused with psychiatrists and draw a blank when asked their specialty.

Val wasn’t done yet, She posted this comment on my blog”

Dear Dr. Reece,

Movement therapy is indeed a wonderful thing, and I applaud the work of Physical Therapists. Do keep in mind, though, that the field was developed by Physiatrists (the medical specialty of Physical Medicine & Rehabilitation)m and our role in advancing the field and promoting physical activity should not be overlooked.

Comment: Just to make sure I got it right, Val sent me a powerpoint presentation on the history of Physical Medicine and Rehabilitation Medicine “ PM&R : Proud History, Bright Future, “ It was given at grand rounds at St. Vincent Hospital in New York, on February 2, 2006. In it Val goes back to the Civil War. She traces the history of physiatrists in treating amputations and their work with polio and spinal cord injuries, and proceeds to envision a future where physiatrists will deal with geriatric rehabilitation, nutritional rehabilitation, complications of obesity, and research on developing neurostimulator devices to treat those suffering from paralysis.

• In another response to my blog, Julie K. Silver, MD, Assistant Professor, Harvard Medical School, Dept. of PM&R , a blogger in her own right (wordworks2001.blogspot.com) had this to say:

Dear Dr. Reece,

I am always delighted when people point out the tremendous benefits of rehabilitation medicine which is led by physicians who opt to specialize in a small, but important medical specialty called Physical Medicine and Rehabilitation (PM&R).
Those of us who complete medical school and then a four year internship and residency training program and go on to become board-certified physiatrists do much more than prescribe physical therapy, however.
Though we used to be called "physical therapy doctors" modern physiatrists are quick to point out that this is a very antiquated term and that while we work closely with our physical therapy colleagues and we certainly write very specific orders for PT to help people physically recover, we do much more than that including prescribing medications, ordering medical studies, performing many types of injections, and so on.
The list is long; however, for more information about physiatrists visit the American Academy of Physical Medicine and Rehabilitation website at www.aapmr.org.

Comment: So there you have, two prominent physiatrists setting me straight on the past, present, and future accomplishments of their distinguished specialty. Physiatrists, who tends to be on the backlines of care rather than in the frontlines, don’t receive the credit they so richly deserves. It is probably a case of out of sight, out of mind.

I should point out that Drs. Jones and Silver have done and are doing meritorious work outside their specialty and have voiced their views in their respective blogs.

Dr. Jones has undertaken the Herculean task of helping develop a comprehensive website, www.revolutionhealth.com, designed to empower consumers so they can better control their health and their disease through superior information and through consultation with specialists focused on helping consumers.

Dr. Silver was editor- in- chief of a marvelous book The Business of Medicine (Hanley & Belfus, 1998) which was beautifully written and was designed to lead her fellow physicians through the rocks and shoals of modern medical business dilemmas and practices.

I know when I am outgunned. I know better than to challenge the Voice of Reason and the Voice of the Business of Medicine. I apologize to Drs. Jones and Silver. I regret I neglected to mention how physiatry has contributed so much to improving care of patients with neuromuscular disabilities, stroke, amputations, spinal cord paralysis, and traumatic war and civilian injuries. They deserve our gratitude, and they certainly have mine. I feel better now that the egg is off my face.

On Physical Therapists and Keeping Patients Moving

“Keep moving!”

Alistair Cooke, The Patient Has the Floor, Alfred A, Knopf, 1986

The late Alistair Cooke, the famed American-British journalist, in a talk to the Mayo Clinic, observed Brits outlive their American counterparts even though Brits consume more animal fats.

Cooke explained why in these words;

“Britain, I had noticed, maintains rights-of-way across fields and meadows and builds footpaths alongside highways and uses the phrase ‘Let go for a walk’ almost as an idiom. In America you cannot walk across field except in pursuit of a ball with a liquid center – and there are no footpaths once the town ends. The British walk, and cycle and walk, even in the rain. Let us face it, gentlemen, I said –‘They function!’ ”

So Much for the Opening Movement of This Essay

David Cella, senior editor for Jones and Bartlett, the publishing firm that is publishing my book Innovation-Driven Care: 34 Key Concepts in Transformation in late March, called the other day.

He recommended I speak to Dr. David Duvall, a PhD in physical therapy who heads up an organization called Sports Medicine of Atlanta (sportsmedicineofatlanta.com). Cella felt Dr. Duvall and I shared a mutual interest in innovative approaches to medical care.

I called Dr. Duvall. He quickly got to the point. He said his group – composed of physical therapists, physiologists, certified athletic trainers, nutritionists, sports and clinical psychologists, recreational therapists, registered nurses, and pastors - has created a new medical model of care.

Movement Science

The model is based on “movement science.” The model aims to keep patients moving. The model, collaboration between physician therapists and the medical establishment, bridges the gap between the traditional medical model, based on diagnosis and pathology, and the alternative practitioner model, dominated in Atlanta by chiropractors.

Duvall said his group, steeped in the discipline of neuromuscular science, evaluates movement impairment disabilities and enhances performance in athletes and non-athletes as well. Perhaps Duvall’s greatest passion is serving as one of nations’ eleven educational centers for physical therapists seeking a PhD. He says 25% of physical therapists now have PhDs, and the percentage of PhD candidates is growing rapidly.

A Movement Model

Sports Medicine of Atlanta is a direct access, multidisciplinary, specialty primary health care center. Most patients walk-in. The group provides access to unique and specialized neuromusculoskeletal care from a movement science perspective. The organization calls itself an Orthopedic-specialty center, although it has no orthopedic surgeons on its staff. Nevertheless, Duvall’s group regularly refers patients to orthopedists, and vice versa, and consider itself and orthopedic surgeons and other referring doctors as essential ingredients of the medical model.

Movement Integration

At Sports Medicine of Atlanta, state of the art diagnostics, interventions, preventative measures, performance enhancement, and wellness programs are integrated. The group has served Atlanta and Gwinnett County citizens since 1981. To identify the cause of movement-related problems, evaluations are performed and diagnoses established to direct the course of interventions.

Physical therapists, who regard themselves as clinical scientists, coordinate care to be received by each client to maximize his or her potential in recovery and/or enhancement of movement performance. They then design an intervention plan aimed at the treatment of movement impairments and their associated functional limitations and disabilities.

Physical and Manual Therapy

Sports Medicine of Atlanta's offers consumers physical and manual therapy based upon evidence-based approaches to patient management.

The group stresses examination and advanced clinical intervention. Its therapists are adept in achieving positive outcomes with difficult conditions. All physical therapy plans of care are designed or approved by an experienced, board-certified and fellowship trained doctor of physical therapy.

Alternative Practitioner Model

There’s another model out there as well. It’s called the alternative care model, or complementary practitioner model, and is based on the proposition that alternative practitioners, not MDs, can effectively treat patients too. I do not quibble with this assertion, except to point it is based on historical traditions and anecdotal evidence rather than on science and controlled studies. Nonetheless, alternative medicine is immensely popular among its followers.

Patients Seek Alternative Outside Traditional Medicine

Alternative medicine has been growing rapidly because patients want an alternative, outside of traditional medicine, free of third party intervention, focused on “natural remedies,” and devoid of potentially dangerous prescription drugs. Consumers are flocking to alternative practitioners outside the medical model – chiropractors, acupuncturists, homeopathic physicians, naturopathic physicians, message therapists, reflexologists, practitioners of herbal medicine.

Often consumers seek these practitioners out because they fail to find relief or satisfaction from traditional physicians. Many consumers suffer from neuromuscularskeletal disorders that manifest themselves as disabilities impairing movement and decreasing their physical performance. These disabilities include arthritis, neuromuscular diabilities, or mysterious ailments like fibromyalgia or fibrositis, or other causes of stiffness and muscle aches and pains that restrict movement.

Physical Therapists – A Logical Alternative

Physical therapists, as part of the medical model, offer a logical alternative to alternative practitioners. Physical therapist services are widely available. In 2004, there were an estimated 155,000 nationwide. Most work in hospitals, their own offices, or in the organizations like Health South, which has more than 1000 offices across the country.

I praise physical therapists for seeking advanced degrees. May the movement towards the advanced physical therapist movement continue.

What in the World is Going on in Health Care?

What’s going on is fracturing, refracturing, individual markets, fast changes, instability, and a an accelerating transition to a consumer-driven system as employers shift costs to employees and as employees become independent contractors supplying their own benefits. At least, that’s what a former national intelligence official thinks.

A friend of mine, Stephen Barchet, MD, of Seattle, formerly head of Medicine for the U.S. Navy, retired, a proponent of wellness and health programs as the core of health reform, just sent me a presentation by Herb Meyer, formerly a high official on President Reagan’s intelligence team, the first U.S. Intelligence official to predict the Soviet collapse.

Four Major Global Transitions

In the presentation, ‘What in the World is Going On? A Global Intelligence for CEOs,” Meyers speaks of implications of four major transformations on America– the War in Iraq, the Emergence of China, Shifting Demographics of Western Civilization, and Restructuring of American Business.

These are important transformations, but I shall restrict this blog to health care implications of restructuring of American business on American health care. To me what Meyer is saying is profound, but that’s up to you to judge.

Restructuring of American Business and Health Care

Here, for your consideration, are his conclusions.

“The restructuring of American business means we are coming to the end of the age of the employer and employee. With all this fracturing of businesses into different and smaller units, employers can't guarantee jobs anymore because they don't know what their companies will look like next year. Everyone is on their way to becoming an independent contractor. The new workforce contract will be, a Show up at the my office five days a week and do what I want you to do, but you handle your own insurance, benefits, health care and everything else.”

“Husbands and wives are becoming economic units. They take different jobs and work different shifts depending on where they are in their careers and families. They make tradeoffs to put together a compensation package to take care of the family. This used to happen only with highly educated professionals with high incomes.
Now it is happening at the level of the factory floor worker. Couples at all levels are designing their compensation packages based on their individual needs. The only way this can work is if everything is portable and flexible, which requires a huge shift in the American economy”.

“The U.S. is in the process of building the world's first 21st century model economy. The only other countries doing this are U.K. and Australia. The model is fast, flexible, highly productive and unstable in that it is always fracturing and re-fracturing. This will increase the economic gap between the U.S. and everybody else, especially Europe and Japan.”

“At the same time, the military gap is increasing. Other than China, we are the only country that is continuing to put money into their military. Plus, we are the only military getting on-the-ground military experience through our war in Iraq. We know which high-tech weapons are working and which ones aren't. There is almost no one who can take us on economically or militarily. There has never been a superpower in this position before.”

“On the one hand, this makes the U.S. a magnet for bright and ambitious people. It also makes us a target. We are becoming one of the last holdouts of the traditional Judeo-Christian culture. There is no better place in the world to be in business and raise children. The U.S. is by far the best place to have an idea, form a business, and put it into the marketplace. We take it for granted, but it isn't as available in other countries of the world.”

“Ultimately, it's an issue of culture. The only people who can hurt us are ourselves, by losing our culture. If we give up our Judeo-Christian culture, we become just like the Europeans. The culture war is the whole ballgame. If we lose it, there isn't another America to pull us out.”

My Take

You may have a different take on Meyer’s conclusions and their implications that I do. My take is that restructuring of business will drive the U.S. health economy towards individual consumer-driven care and will cause it to restructure to accommodate business fracturing and refracturing.

This, in turn, will culminate in faster, more flexible, more unstable, but more productive changes in the health economy. It will shift health markets towards more individual responsibility, preventive measures, and wellness consciousness.

Meyer obviously hopes the U.S. culture will not seek to mimic the Europeans who depend heavily on government programs rather than marketplace adjustments. It’s secular progressives via a via conservative capitalists. As he says, “The culture war is the whole ballgame.”

Whether the U.S. health care culture will drift from the marketplace to government dependency remains the central $4 trillion (our projected health costs by 2030) of our time. It all boils down to who wins the debate between those who believe the answer lies in mandated and expanded government programs or the free market’s potential to keep costs down and coverage and choices up.

Whatever happens, we’re now moving towards the end of the traditional employer employee relationship, conversion of employees into individual contractors, greater individual responsibility for providing for their own care and insurance, and more flexible benefits in the unique U.S marketplace culture.

I will leave it to you to decide if this new direction is good or bad, humane or inhumane, propitious or malicious.

How to Become a Physician Hero:

“In guerilla country a handcar, light and expendable, rides ahead of the big lumbering freight train to detonate whatever explosives might have been placed on the track.”

Peter F. Drucker, The Age of Discontinuity, Harper & Row, 1968

Many health care safety innovations fill gaps in a system supposed to be continuous. Doctors can become heroes by serving as early-warning systems for patients, forewarning what lies ahead.

This blog is for doctors. Its purpose is to ensure safety of patients by informing them what to expect.

• Begin by giving patients written information about common hospital dangers. In the 1999 Institute of Medicine’s report To Err is Human hospital errors were reported to cause as many as 100,000 deaths a year in hospitals.

• Follow by “prescribing” patients online information for filling care gaps with interactive videos. The videos tell patients what surgical procedures and chronic disease episodes entail. They explain in simple, clearly illustrated, empathetic language possible dangers and complications.

Health Care Gaps

“Gaps” personify health system “fragmentation.” Gaps occur at multiple junctures, inside and outside hospitals,

• when patients are transferred from one location to another within the hospital;
• when seriously ill patients are left unattended in hospital wards;
• when patients are relocated to rehab facilities;
• when patients leave hospitals to go home,
• when patients go to pharmacies with illegible prescriptions,
• when patients are not properly instructed how to remove or insert urinary catheters or give IM injections, use bronchodilators, or perform other procedures;
• When patients are not taught to recognize complications, like gaining weight in heart failure.

Many gaps happen during “hand-offs” or transfers, within hospitals, from hospitals to other facilities, from doctors to hospitals, from doctors to care sites outside their realm, in short, in gaps between settings.

Filling Gaps in Young Patients

For pediatricians and those who give anesthesia or operate on children or adolescents, the process of filling gaps is important, Because of smaller size, children may experience special anesthesia problems and adult doses of antibiotics or pain killers may endanger them.

I have a young friend in his 30s. Twenty years ago, a cardiorespiratory arrest after a routine cosmetic jaw procedure permanently disabled him. In the recovery room, a nurse gave him a dose of Demoral. After being transferred to a pediatric ward, a second nurse gave a second dose of Demoral, a respiratory depressant. The second dose caused a cardiorespiratory arrest with prolonged oxygen deprivation and irreversible brain damage, with ensuing gait disturbances and inability to read.

Preventable Medical Errors

I thought of my young friend, an invalid for life, when I read these paragraphs in a March 7, 2007 New York Times story, “Medication Errors are Studied,”

“Young children are the most likely victims of surgery-related medication mistakes, a new study has found, and poor communication as the patient moves from the operating room to recovery is the most likely culprit.”

“The study was confined to errors made on patients undergoing surgery, and the rate of harm, 5 percent, was much higher than is typical for medication errors. Among children it was 12 percent.”

“Most of the errors involved painkillers and antibiotics. Four resulted in deaths, and one death was of a child.”

“Problems typically arose when a patient was handed off from the preoperative team to the operating room to the recovery room to the regular ward nurses.”

A Preventable Triple Tragedy

My friend was disabled. The surgeon and hospital were sued. The settlement requires an insurance company to pay for lifetime care, which may last 70 years after the event. Both the disability and malpractice suit were tragic enough. But also tragic was the fact that the hospital and the surgeon had no systematic way of preventing the tragedy.

The patient fell through three care gaps.

• Lack of communication between nurses in separate hospital units.
• Giving two adult doses of Demoral, a known respiratory depressant to a young patient whose jaw was wired shut who could not communicate.
• Placing the patient on a pediatric unit, ill-equipped to handle a respiratory arrest. He should have been held longer in the recovery unit.

Six Most Common Hospital Safety Gaps

Today, such tragedies may be prevented. Hospitals are beginning to focus on six common mishaps.

Donald Berwick, MD, founder and leader of the Institute of Healthcare Improvement in Boston, outlines six steps, which may prevent 100,000 deaths each year:

1) prevent ventilator-associated pneumonia (VAP);
2) prevent IV-catheter infections;
3) stop surgical cite infections;
4) respond rapidly to early warnings;
5) make heart attack care reliable;
6) end medication errors.

On the sixth point, Berwick advises: “Reconcile medications whenever patients move from one care setting to another, even if it occurs within the hospital.”

Preventing these mishaps falls mostly on hospitals’ shoulders. But informed doctors and alert patients can help too. They can insist ventilator patients be sat up in bed with mouths cleansed; remind nurses catheters need to be changed frequently; advise hospital personnel not to shave surgical sites; stay with critically patients and carefully watch for distress; insist heart attack patients be placed on aspirin and beta-blockers; and make sure medications are re-checked during in-hospital transfers. Safety requires eternal vigilance by all every step of the hospital stay.

The Surgeon as Victim

In the case of my young friend, the surgeon was a psychic and monetary victim. Many disillusioned doctors retire after losing malpractice suites. The malpractice attorney maintained the surgeon should have anticipated what might happen and should have spelled out the complications forcefully in the informed consent process prior to surgery. But, of course, the surgeon, though he had the parent perfunctorily sign an informed consent form, expected nothing to happen. He probably felt he should not have been held responsible for post-operative nursing mistakes outside the OR. The problem, he might have said, was in the system, not with him.

Power of Advance Patient Engagement

Which brings me the subject at hand – the power of patient engagement before the time of need, before the patient enters the hospital, before the procedure, when the patient and his family are focused on the impending event, when they can be told what is to happen and what might happen.

How can this “engagement” be facilitated and rendered relevant? Emmi Solutions, Inc, for purposes of disclosure, is a Chicago company with whom I am affiliated as an industrial advisory board member, engages the patient by developing online, simple, relevant, personal, three-dimensional, interactive videos.

Doctors “Prescribing” Advance Explainations for Patients

Doctors “prescribe” by giving Internet access to videos to patients and families, who, in turn, download videos in advance of surgery and study them.

The videos are three dimensional -- they feature a soothing voice leading them through what’s about to transpire, provide medical illustrations to visualize , and explain events in 6th grade language.

In chronic disease management, the videos have three purposes:

1) Engaging and educating patients before or during a very personal experience;

2) Changing patient behavior by informing them in advance of adverse consequences;

3) Measuring outcomes of engagement, education, and changed behavior.

A Fundamental Difference – Taking the Initiative

These videos may seem like just another layer of unneeded information to those already reeling from information overload.

But there is a fundamental difference.

In this consumer-driven age, patients often take the initiative by presenting the doctor with downloaded information from the Internet – information the doctor may not be aware of and which the doctor may regard as irrelevant or misleading.

Information gaps between patient and doctor may create tensions between patient and doctor. They may circle each other, struggle to define what each other knows, and pit their knowledge against one another.

In the case of doctor “prescribed” information, the doctor takes the initiative by presenting relevant, simple-to-understand, three- dimensional information when it is most needed, before the clinical event – real-time in time.

The patient may react by saying, “My doctor told me exactly what to expect, what to be prepared for, and what complications to avoid.” That leaves little room for misunderstandings, builds trust, and makes the doctor a hero rather than the villain.

Innovative Strategies to Reduce Malpractice Risk

This article appeared in the February 7, 2007, edition of Physicians’ Weekly, a newsletter that appears in poster form in staff lounges and other physician gathering places in 1600 U.S. hospitals. The newsletter is estimated to be read by 250,000 physicians each week.

I submit it as a blog because reducing malpractice exposure remains an overriding concern among hospitals and physicians. Also I believe solutions to malpractice often reside in taking systematic, innovative steps to circumvent malpractice rather than in complaining about attorneys and campaigning for tort reform.

The article begins:

Focusing efforts on patient safety and education and identifying valuable resources can help practices reduce their risk of future medical malpractice claims and suits.

Medical malpractice claims are of great concern and are the basis by which many physicians make decisions on their choice of specialty right through to deciding on when and how to retire. According to Richard L. Reece, MD, there are many steps that physicians can take to reduce their risk of being involved in a malpractice claim (Table 1).

Table 1 --7 Steps to Reducing Malpractice Risks

By performing the following steps, physicians and practices from all backgrounds and specialties can reduce their risk of incurring malpractice suits.

1. Carefully document each patient encounter and do it electronically when possible.
2. Provide patients with a record of the details of their visit before they leave the office.
3. Communicate thoroughly via conversations and paper documentation.
4. Ensure that patients completely understand what they being told and have them repeat what was said.
5. Spot litigious patients. These individuals:
• Are more likely to have psychological problems.
• May present with information from the Internet.
• Often have a history of suing doctors.
• Are likely to have complex problems.
• Have a history of seeing multiple doctors.

6. Have patients sign informed consent forms and waivers to disclose that they will not sue for frivolous reasons.
7. Inform patients about their condition using patient education materials.


“While there are many things that can be done to lower the risk of malpractice suits,” he says, “the most important consist of identifying patients who are prone to such claims, practicing safe medicine, educating patients, incorporating risk-management systems into hospitals, and utilizing alternative-risk organizations.”

Tackling Patient Safety

According to Dr. Reece, being aware of patients who are prone to submitting malpractice claims is one of the key steps to avoiding them. “If physicians can spot potentially litigious patients, they are doing themselves a great service. These patients may have a history of suing physicians and are more likely to have psychological problems. Typically, this patient group presents with very complex problems. They’ll come in with information they obtained from the internet and may seek treatment from multiple doctors. If a patient demonstrates these characteristics, it’s important to carefully document the visit, communicate with the patient, and repeat what is said. Another helpful tactic is to have patients sign a consent form and waiver that they will not sue for frivolous reasons.”

Practicing safer medicine is another important aspect to reducing the risk of malpractice, adds Dr. Reece. “Throughout the past 20 years, anesthesiologists have taken measures to greatly improve the safety of their practice, including practicing procedures on mannequins and using pulse oximetry to measure blood oxygen levels and other devices to detect carbon dioxide levels. Taking similar precautions in practice settings can reduce your malpractice risk.”

Safe practices also need to be addressed in hospitals. Recently, the Institute of Medicine launched the “100,000 Lives Saved” campaign to lower the number of deaths that occur in hospitals; since its introduction, the campaign has been incorporated into about 3,000 hospitals. It includes six important measures that physicians and hospitals should follow to reduce malpractice (Table 2). Learning more about this campaign can provide valuable strategies and insights, according to Dr. Reece.

Table 2 - ^ Steps to Improving Patient Safety

The Institute of Healthcare Improvement’s “100,000 Lives Campaign” aims at reducing the number of annual deaths that occur in the hospitals. Six methods are cited as methods to improve hospital safety and patient outcomes.

1. Prevent ventilator-associated pneumonia (VAP). Simple maneuvers (e.gl, elevating the head of the hospital bed, frequently cleaning the patient’s mouth) can eliminate VAP.
2. Prevent IX-catheter infections: Adopt simple procedures for changing bandages around cathers and make sure no catheter remains in a vain longer than needed.
3. Stop surgical cite infections: Hospitals should give the appropriate antibiotics at the recommended time during surgery, enforce hand-washing practices, and avoid shaving the surgery cite before the operation.
4. Respond rapidly to early warnings: Setting up special-response teams can help hospitals to ensure that critical warnings are not missed or ignored. Take family members and nurses concerns seriously, and respond within minutes.
5. Make heart attack care reliable: Hospitals should ensure that every heart attack patient gets every treatment and medication recommended by the American College of Cardiology and other experts. These measures often include aspirin and beta-blocker therapy upon arrival and may require stent implementation or a clot-busting agent promptly after admission.
6. End medication errors: Reconcile medications whenever patients move from one care setting to another, even it it occurs within the hospital.

Patient Education Plays a Vital Role

Patient education is another important aspect of reducing the risk of malpractice suits, indicates Dr. Reece. “Managing patient expectations about their care is key, especially because many of these individuals have unrealistic ideas on what their procedure or treatment will entail. One group, Emmi Solutions, is now offering a new service to educate patients on exactly what to expect when entering the hospital for a procedure. This online resource allows physicians to register for and ‘prescribe’ detailed videos to their patients. Patients access the system with an account number provided by their doctor and view videos explaining what to expect in simple, sixth-grade reading level language. So far these videos have been incorporated into over 400 medical groups and used by approximately a half million patients; no malpractice claims have ensued.” Dr. Reece adds that this resource appears to be of great value because many claims can result largely from patient misunderstanding rather than physician negligence.

Risk Resources Help Manage Risks

Risk-management systems in hospitals also play a significant role in the fight against malpractice claims. “These systems consist of a dedicated manager to manage all aspects of risk within a hospital,” explains Dr. Reece. “Such duties may include credentialing doctors, filling out incident reports, following up on patient complaints, documenting claims, and educating physicians on sensitivity to patient complaints and offering apologies. We need to remember that apologies play a large role in malpractice; simply offering an apology and admitting that an error was made may reduce the number of malpractice claims.”

Physicians can also protect themselves against malpractice claims by enrolling in alternative-risk retention groups. “These groups are set up off shore,” Dr. Reece says, “but offer malpractice insurance to U.S. physicians. Such groups are necessary since finding American-based insurers is becoming increasingly difficult. Adding to the growing popularity of these groups is the fact that they offer the same coverage as conventional insurers but at a lower price.” While these groups can help lower the rising costs of malpractice claims, it is important to note that they are not yet accepted in all 50 states.

What Does the Future Hold?

The steps Dr. Reece discussed are important when assessing the risk for malpractice suits, and he says that simply initiating any one of these steps can help reduce risks. “Recent studies have shown that the rate of malpractice suits in the United States is leveling off. In order to keep this level steady and perhaps reduce it over time, following these simple steps is critical.”


Reference Links

For more information on Emmi Solutions, visit www.emmisolutions.com.

Dr. Reece authored an article titled “Managing Malpractice Risk” that was published on the Hospitals & Health Networks website. To access the article, go to http://www.hhnmag.com.

Szalados JE. Legal issues in the practice of critical care medicine: A practical approach. Crit Care Med. 2007;35(2 Suppl):S44-S58.

Taheri PA, Butz DA, Anderson S, et al. Medical liability—The crisis, the reality, and the data: The University of Michigan story. J Am Coll Surg. 2006;203:290-296.

Vukmir RB. Medical malpractice: Managing the risk. Med Law. 2004;23:495-513.

Johnson WB 3rd. Managing risk in a risky world. J Miss State Med Assoc. 2003;44:219-224

Kevin Pho, MD - King of the Medical Bloggers

Kevin Pho, is a board-certified internist in his 30s. A Toronto native educated at Boston University and Boston University Medical School, Kevin practices with the Nashua Medical Group, a seven person provider group(5 physicians, 2 physician assistants, and one nurse practitioner )in the Nashua Medical Group in Nashua, New Hampshire. Kevin, in my opinion, is King of the Medical Bloggers (see Kevin, MD.com).

An Act of Gratitude

I am writing this out of gratitude because Kevin has been citing some of my blogs, medinnovationblog.blogspot.com. One good blog deserves another, especially when one links to another. Kevin has been blogging since 2004 and now receives 6000 “hits” daily and 170.000 hits each month. I should be so lucky, or so good.

Kevin specializes, he says, in “ medical information research“ which he conducts in part by scouring the news media daily, linking to original medical articles and other blogs, answering patient emails, and “posting” (that an inside term we bloggers use) his daily commentary.

Telling it As It Is and Striking a Nerve

His comments are pithy, short, and “tell it like it is” from the vantage point of a primary care physician. Like his cohorts, Kevin sometimes must see one patient every 6 minutes to stay on schedule and to make a go of it. This requires discipline and may be in part why Kevin is so quick, insightful, and so appreciative of patients' thirst for information.

Kevin has clearly struck a nerve. His work has been featured in the British Medical Journal, the Wall Street Journal, the New York Times, MD Net Guide, Modern Physician, the Journal of Medical Practice Management, Medscape, and the Nashua Telegraph.

He serves as moderator of physician forums on gastroenterology, general medicine, urology, and joint disease. He invites emails from readers, charges an average fee of $15 for answering, and says he succeeds because his answers have speed (responses within 48 to 72 hours), quality, and depth. Kevin’s work is so compelling that several sponsors are helping subsidize his popular blog.

Summary

There once was a medical blogger named Kevin,
who blogged each day every week times seven.
Kevin tells it as it is.
At this he is a whiz,
which qualifies him for blogging heaven.

This dashing blogger, a native of Toronto,
knows the meaning of the word pronto,
To emails requesting complicated medical information,
he replies within in forty eight to seventy hours duration.
How’s that for speed, depth, and quality of Pho info?

This young doctor is such a mover and shaker,
he has achieved the status of a national news maker,
He blogs so fast, this young doctor from Nashua,
readers have to stop and their breaths catchua.
That’s how life is with this media circuit breaker.

The Business Case for Hospital Case Management: Bedside Thouhgst

By Stefani Daniels and Richard Reece, M.D., for HealthLeaders News, March. 1, 2007
Stefani Daniels is the primary author here. Most of these words are hers. I have modified the article slightly for the purposes of this blog and I added a short epilogue based on a conversation with my wife, Loretta, a graduate of the Massachusetts General School of Nursing
Stefani is a managing partner with Pompano Beach, Florida.-based Phoenix Medical Management, Inc. She may be reached at daniels@phoenixmed.net. I am coauthor with James Hawkins of Sailing the Seven “C’s”of Hospital-Physician Relationships: Competence, Convenience, Clarity, Continuity, Competition, Control, and Cash. I can be reached at rreece1500@aol.com

Introduction of Case Management

When case management was introduced in hospitals in the mid 80s, it was accompanied by a promise to control costs at the bedside. It was thought nurses caring for patients were in the best position to manage and ensure appropriate use of acute care resources with an eye for improving quality and reducing costs. The idea was admirable, but the execution was a dismal failure.

Case Management Relegated to Nurses

But the re-engineering craze of the 1990s, reduction in medical social workers, and rapid spread of 12-hour nursing shifts, created continuity gaps. Case management was relegated to nurses for utilization management and discharge planning activities.

Because their work was heavily centered on utilization review tasks, nurses became the “chart police” and served as instruments for growing chart review activities, such as core measure abstracting, medical documentation review, concurrent coding assignments, safety indicators, and numerous other performance improvement projects. The idea of resource appropriateness, advocacy, navigation through the episode of care, cost reductions and improved quality vanished, except for an obligatory mention in the job description.

Spotlight Returned to Case Management Team

Recent incentives have returned the spotlight to the hospital’s case management team. As pointed out in the epilogue, this team should include a head nurse. Desire to improve relationships with medical staff, continuing refusal of insurers to pay for non-acute services, growing regulatory pressures, and expansion of quality and safety measures are among reasons why executives are rethinking how valuable and scarce professional resources can be more effectively mobilized to fulfill their original promise.

From our respective positions, as a hospital case management consultant and as a physician interested in hospital-physician management, there are several issues that are contributing to this renewed interest in case management.

• For starters, there is a new understanding that to be effective, case management must operate along entire acute care episode beginning with access-to-care, through care management/through-put and capacity, and ending with transition to a lower level of care or discharge back to the community.

• Furthermore, recent Corporate-suite chats regarding traditional utilization review activities indicate executives are questioning value of committing professional resources to perfunctory chart review when they might be more beneficially positioned to work alongside the physician to potentially influence decisions before they are committed to a medical record.

Case Manager at Bedside with Physician

This is a relatively new phenomenon measured by the increased calls we get directly from Corporate -suite occupants. They intuitively know case management programs have to be redesigned so that a case manager is placed at the bedside with the physician who, after all, controls 80 percent of all clinical costs and whose decisions directly and indirectly effect patient quality and safety.

Role of Employed Hospitalist

The explosion of employed hospitalists is another reason many executives cite to explain why they need help to transform their case management program. As contracted employees, hospitalists often have economic incentives based on quality and financial outcomes. We are frequently asked how to create partnerships that allow the physician to concentrate on managing care while the hospitalist’s case management partner concentrates on the business of managing care.

Effective Gatekeeping

Another driving force is the issue of effective gatekeeping. Access-to-care functions are so fragmented in the average hospital that financial officers find themselves budgeting more and more personnel to post-event fixes in the form of reversing admission status designations, denial management, appeal processes, revenue cycle coordinators and the like.

Consolidating all access-to-care functions under a single administrative umbrella, using case managers and social workers in the emergency department and creating a single, consistent case management process for direct, transfer and emergency department inpatient referrals are among the objectives that find their way into our portfolio.

Demands and Dilemmas of Evidence-Based Medicine

Physicians have been increasingly challenged as consumer knowledge of available treatment options has increased over the years. Public awareness of new treatment interventions and research findings have steadily increased through the media including screaming headlines citing failures.

While the demand for evidence-based medicine is growing rapidly, medical staff acceptance remains tenuous at best. Physicians need reminders to put post-MI patients on beta-blockers or to prescribe aspirin for patients with coronary artery disease. As long as physicians are reimbursed independently from the hospital, the benefits of a level quality playing field are lost. Physician practice decisions affect the hospital and the patient but have little or no economic or credentialing repercussions for the private physician. Unless there is blatant and persistent disregard for the well-being of the patient, hospitals are loathe to strip a physician’s credentials for fear of litigation and the loss of a patient referral source.
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So, What’s a Hospital to Do?

Chief medical officers look to case managers to work with selected physicians on a real-time basis to inform, educate, and counsel at the point-of-care. I’ve been told that using objective and comparative practice data coupled with a dedicated case manager works wonders for the obstinate physician.

Flawed delivery-of-care systems are often cited as examples as the inefficiencies that physicians and patients encounter daily. There is general consensus in the Corporate-suite that they want a case management program that will overcome delivery-of-care obstacles so that length-of-stays are appropriate.

Unfortunately case managers have no positional authority to streamline delivery-of-care processes, but they are quite knowledgeable about how hospitals operate. They know, for example,

• physicians will order stat lab tests because turnaround time for routine requests will delay a patient’s treatment plan.

• unless a PT consult is written on day one of a orthopedic admission, waiting for a rehab consult may add unnecessary acute, inpatient days.

Obstacles to Efficiency Everywhere

Obstacles to efficiency are everywhere, but little accountability exists to remove or at least minimize them. While case managers are busy trying to expedite key delivery-of-care processes on behalf of the patient, they are also capturing objective information that they will present to the decision-makers about how much a particular barrier to efficient delivery-of-care is costing the hospital in terms of financial risk (lost reimbursement) or clinical risk (excessive length of stay). At that point, it becomes a business decision made by the executive team whether to hold the process-owners accountable for redesigning their internal systems to better meet customer needs.

Summing Up

Physician relationships, a growing number of hospital-based physicians, protective gatekeeping, promoting evidence based practice, and overcoming delivery-of-care barriers are just some of the issues cited by farsighted executives as reasons to reinvent their hospital’s case management program. It’s a far cry from the days of perfunctory utilization review and discharge planning, but it’s still an illusive goal in many hospitals.

As chief advocates and patient navigators in an increasing complex and seemingly intractable health care system, hospital case managers deliver a return on investment in hard currency and stronger physician relationships. These valuable assets should not be squandered in a corner conducting chart review. Today’s hospital case managers practice from an entirely different mental model then that of their predecessors and warrant closer attention and greater support.

Epilogue:

My wife and I discussed what is being said here, and she commented, and I paraphrase, “When you refer to the ‘case management team,’ highlight the head nurse as the one who leads the team on the ward. The head nurse, in essence, is the head case manager there. The head nurse, overseeing the ward’s overall human activities and coordinating care between doctor, nurses, and other personnel, is the one responsible for creating the best care environment. She is the concert conductor, orchestrating everyone to play the same music -- getting the patient well.”

“The system veered off course when ‘team nursing’ came into play. That concept disrupted harmony between patients and doctors, who used to make rounds together, and put the nurse behind the chart desk, rather than at the bedside with the physician.

The nurse-doctor interaction is where the action ought to be. As Mass General, they told us they were training us to be ‘little doctors’ and to think like them and help them. Our instructors were right.”

The Chart before the Horse

Last week I visited a relative in a circular ward in an academic health center. In the middle of the ward’s central circle sat a dozen nurses, doctors, and aides. I did not see any medical students, but it was hard to tell because everybody was wearing blue hospital garb. Most people in the inner circle wore no name tags.

No Eye Contact

As I entered the ward, nobody raised their heads or made eye contact, or showed other signs of recognition. I saw no health care personnel visiting patients in their rooms, listening, looking, checking, and examining. During my three hour visit, I saw no evidence of nurses and doctors working in tandem at patients’ bedsides, the sine qua non for clinical efficiency (see tomorrow’s blog on the “The Business Case for Hospital Case Management.”)

Eyes Glued to Computer Screens

To computer screens all eyes were glued. All hands were clicking computer keys, either entering or retrieving data with that omnipotent mouse. They were feeding or extracting information from that omnivorous and never-forgetting data-eating and data-spewing monster called the electronic chart, now more properly dubbed the electronic medical record.

The Chart Ritual

This experience reminded me of when I was a Duke medical student. A red-headed intern with a sense of humor oversaw students. Before rounds he would pull all the charts, review each, and begin his recitation, “This three day-old chart presents without a urinalysis, a CBC, and a chest x-ray.” His tongue-in-cheek message was that a completed chart superceded the patient.

Today this ritual is more important than ever, for everything in this fast-paced fee-for-service world, must be entered, charged, coded, and documented by computer, lest something be overlooked, a diagnosis missed, or an attorney discover a sin of omission.

Data entry has thus become King of the Ward, Supreme Ruler of the Dark Data Domain, and health care professionals have become data entry serfs. Nurses are now the chart police and paper tigers. They spend more time policing and prowling through the chart than nurturing, observing, and caring for patients and collaborating with doctors.

Test First, Talk Last

A fellow intern, now an internist who hangs out at a teaching hospital, tells me in this technological age, interns and residents believe technology testing – CT and MRI scans, echo studies, blood tests – takes precedence over the medical history and physical examination.

Present day monitors of medical students must be intoning, “This three day chart presents without a full technological workup.” The nurses are part of the parade and conduct chart rounds of their own, a task most would rather disown.

A Closing Verse.

Putting the chart before the horse,
is doing first what’s better done later,
putting charts first as a matter of course.
saying to patients, “See you later alligator.”

Treating the chart before the person
has become an obsession and a curse.
I believe it is only going to worsen.
To me it is medical care in reverse.

“Please,” clerks say, “fill out this form.”
You’ve done countless times before.
Still you fill in the blanks and conform,
with data given too often heretofore.

This obsession with documentation,
has to do with payer compensation,
with multi-layered administration,
ending with endless data collection.

When you go through hospital admissions,
it gets worse, time spent on paperwork.
on what are to be your payment conditions.
It is quite enough to drive you berserk.

But for me what is absolutely disconcerting,
is the complete lack of human eye contact.
Total attention to the computer is diverting,
as if you were not even there in actual fact.

Computer hypnosis mesmerizes doctors too.
They sit glued behind that infernal screen,
treating the chart as if it were really you,
acting as slaves to that flickering machine.

So you doctors obligated to give care,
lift up your eyes and open your ears.
Listen to nurses, patients, and visiting folks.
They take precedence over digital strokes.

Hospital CEO Pay – Compared to What?

Paul Levy, CEO of Beth Israel Hospital in Boston, started his blog, “Running a Hospital” in August 2006. Levy’s blog is a free-wheeling, snappy, insightful commentary on hospitals, health care, and medicine.

His January 28 entry, “Do I Get Paid Too Much?” received 23 responses-- huge in the blogosphere. Levy’s annual $1 million pay incensed a few physician responders.

In an American Medical News interview, Levy defends his pay by saying the hospital board determines his annual salary, and besides, his pay is at the lower end of hospital CEO pay for non-profit hospitals in Massachusetts (Dolan, Pamela, “Do I Get Paid Too Much,? Hospital CEO Raises the Question. The Blogosphere Chimes in with Opinions,” American Medical News, page 18, March 5, 2007.)

Table 1 - Executive Pay for Massachusetts Hospital CEOs

1. James Mongan, MD, Partners Healthcare, $2.1 million
2. Elaine Ullian, Boston Medical Center, $1.4 million
3. John O’Brien, UMass Memorial Medical Center, $1.3 million
4. David Barrett, MD, Lahey Clinic, $1.3 million
5. Mark Tolosky, Baystate Health, $1.2 million
6. James Mandell, MD, Children’s Hospital, Boston, $1.1 million
7. Gary Gottlieb, Brigham and Women’s Hospital, $1 million
8. Peter Slavind, MD, Massachusetts General Hospital, $1 million

Source: “Hospital CEO’s Join the $1M Club,” Boston Globe, August 21, 2006. ). Please note that ½ of these CEOs are MDs. Some responders complaining the most were MDs. They may not be aware growing numbers of hospital CEOs are doctors.

Levy’s blog inspired the title for this blog “Hospital CEO Pay – Compared to What?” In America’s capitalistic culture, CEOs are generally paid for the size, scope, and revenues of enterprises they lead. They are also paid salaries comparable to other CEOs. Many of America’s 5000 hospitals have revenues exceeding $100 million, and some large hospital systems these revenues top $1 billion. What is the CEO worth who runs these hospitals, often the largest employers in any given community? Some people consider health care jobs as a sacred duty, immune from the laws of economy gravity, and protest that even highly trained professionals should work for a pittance. I am not one of these people.

In any event, I decided to have a stab at answering “ Hospital CEO Pay: Compared to What?

I started with the MGMA 2006 survey of physicians’ compensation. The survey is misleading in that it simply lists the compensation for “all physicians” in a given specialty. Undoubtedly, those at the top of the specialists’ compensation heap make considerably more, some $1 million or more.

Table 2 – Compensation for “All Physicians” in Selected Specialties, MGMA 2006 Compensation Survey

1. Orthopedic, spinal surgery, $554,000
2. Neurosurgery, $476,000
3. Heart surgeons, $470,000
4. Diagnostic radiology, Interventional, $424,000
5. Sports Medicine, surgery, $417,000
6. Orthopedic Surgery, $400,000
7. Radiology, non-interventional, $400,000
8. Cardiology, $363,000
9. Vascular surgery, $354,000
10. Urology, $349

Source: 2006 MGMA Physician Compensation Survey

Then I proceeded to find what Health Plan CEO executives are paid. Last year news came out that William McQuire, MD, CEO of United Healthcare Group, had fudged by post-dating $1.6 billion in deferred compensation. This billion dollar number created such a flap that McQuire was ousted from this job.

I found the following information in a AIS (Atlantic Information Service) newsletter. This is compiled from company proxy statements and may be the tip of the iceberg because it does not include delayed compensation.

Figure 3 --2005 Total Annual Compensation for Publicly Traded Managed Care CEOs, Total includes annual salary, bonuses, and other annual compensation, but not deferred compensation

1. United Health Care $8.3 million
2. Wellpoint, Inc, $5.2 million
3. CIGNA, $4.7 million
4. Sierra Health, $3.4 million
5. Aetna, Inc, $3.3 million
6. Assurant, Inc, $2.3 million
7. Humana, $1.9 million
8. Health Net, $1.7 million

Source: Atlantic Information Services, compiled from company proxy statements. Reprinted from the April 24, 2006, issue of Managed Care Week, a leading source of business, financial and regulatory news of health plans, PPOs, and POS plans.

From Forbes Magazine, here are the top ten compensations for American corporate CEOs, which makes health care compensations pale in comparison.

Figure 4 --Top Corporate CEO Compensation

1. Capital One Financial, $249 million
2. Yahoo, $231 million
3. Cedant, $140 million
4. KB Home, $135 million
5. Lehman Brothers Holdings, $123 million
6. Occidental Petroleum,, $81 million
7. Oracle, $75 million
8. Symantec, $72 million
9. Caremark Rx, $70 million
10. Countrywide Financial, $69 million

Source: Special Report, CEO Compensation, Forbes, May 20, 2006

Finally, here is Forbes 2006 list of the world’s top ten billionaires – not a U.S, hospital CEO or U.S, physician in the bunch I regret to say.

Figure 5- Forbes list of worlds top ten billionaires

1. William Gates III, Microsoft, $50 billion
2. Warren Buffett, Berkshire Hathaway, $42 billion
3. Carlus Slim Helu, Telecom, , $30 billion
4. Inguar Kasmpral, Ikea, $28 billion
5. Lakshoni Mittel, Steel, $23.5 billion
6. Paul Allen, Software, $22.0 billion
7. Bernard Arault, LVMH, $21.5 billion
8. Prince Alwaleed Bin Talal, $20.9 billion
9. Kenneth Thomson and Family Publishing, $19.5 billion
10. Li Ka-Shing, Self-Made, $18.8 billion

Source: Forbes Magazine, “The World’s Billionaires,” March 9, 2006

What’s “fair” about these high incomes in various economic sectors resides in the mind of the beholder. If you’re in health care, corporate CEO’s high pay may strike you as an abomination. If you’re a corporate CEO, you may say, “The board sets my salary. Anyway, that’s the way we pay the game in Corporate America.” If you’re a self-made billionaire, you may say,“ I did it my way.”

Hospital CEO and physician pay reflect American culture, our free-enterprise capitalistic system, and what it is willing to pay its corporate, health, and physician leaders. Government, or the health industry, could, of course, attempt to regulate pay of health care leaders and downgrade incomes, but that is unlikely to happen.

As far as the fairness of pay to health plans, hospitals, and physicians, and whether its leaders should be paid less because they are in sacrosanct health care fields, it may come down to that old saying, “When they say it’s the principle, and not the money, it’s the money.” When I look at the comparative numbers, I wonder if hospital CEOs and doctors are paid enough.

The purpose of this blog has not been to flog hospital CEO’s pay, but to put that pay in context.

In Innovation; Emphasize the Big Idea: Readings on Innovation from The Daily Drucker (HarperBusiness, 2004)

Prologue: Here Peter Drucker speaks of making a list of your three best ideas and acting upon them. What are the three big ideas in health care innovation?

My top three are:

1) learning from health care consumers—through focus groups, satisfaction surveys, and clinical experiments -- what they want and quickly delivering it;

2) engaging caregivers on the front lines of care, asking them what works best, and implementing necessary changes;

3) seeking effective, systematic, and understandable ways to educate patients at the points of care at which they need the information the most and filling in the gaps.

Others have loftier goals – universal coverage, ubiquitous information systems, unified collaboration. I applaud their efforts. My innovations are more modest – but more doable. One man’s frog eggs are another man’s full-grown frogs.


In Innovation, Emphasize the Big Idea

Innovative ideas are like frogs’ eggs: out of a thousand hatched, only one or two reach maturity

The innovative organization understands that innovation starts with an idea. Ideas are somewhat like babies – they are born small, immature, and shapeless. They are promise rather than fulfillment. In the innovative organization executives do not say, ”This is a damn fool idea.” Instead they ask, “What would be needed to make this embryonic, half-baked, foolish idea into something that makes sense, that is feasible, that is an opportunity for us?”

But an innovative organization also knows that the great majority of ideas will not turn out to make sense. Executives in innovative organizations therefore demand that people with ideas think through the work needed to turn an idea into a product, a process, a business, or a technology. They ask, “What work should we have to do and what would we have to found out and learn before we can commit the company to this idea od\v your?” These executives know that is as difficult and risk to convert a small idea into successful reality as it is to make a major innovation. They do not aim at “improvements” or “modifications” in products or technology. They aim at innovating a new business.

ACTION POINT: Make a list of your best three ideas. Then make a list of the key pieces of information you need to know and the major work that needs to be done before these ideas can blossom into a new business. Now pursue the best idea, or if none is practical, start again.

Information Prescription: A Primary Care E-Mail Innovation from America’s Heartland

Scarcely a day passes without another commonsensical innovation coming from a doctor who’s been there and done that and who knows what doctors can deliver and what patients want.

In this case, that doctor is Charles Smith, MD, 57, a practicing family physician in Little Rock, Arkansas, who wears three hats:

• founder in 1998 of EDocAmerica.com,
• associate dean of the University Of Arkansas Medical Sciences College Of Medicine (UAMS) in Little Rock,
• teacher and attending physician at UAMS.

Dr. Smith is also the Executive Associate Dean for Clinical Affairs at the University of Arkansas for Medical Sciences (UAMS) and is a Professor in the Department of Family and Community Medicine there, where he has been working since 1989.

In his role at the University Of Arkansas Medical Sciences College Of Medicine, he also serves as the Medical Director for UAMS Medical Center and as Physician Director of Medical informatics. He is responsible for initiating and implementing software programs to assist physicians to provide care at UAMS and for overseeing quality of medical care at UAMS. Dr. Smith is clearly a man of all seasons for all the right reasons.

Dr. Smith has long been a leader in American Academy of Family Physicians circles. In his own company, EDocAmerica, Inc, he has gathered together 12 primary care national leaders – 10 family physicians, 1 internist, and one psychologist – to answer emails from concerned patients on a secure website, eDocamerica.com. In his career as a family doc, Charlie has learned about ½ of patients don’t really need to come to the office to be seen – what they want and need is more information about treatment and doctor options.

Employee groups who desire to provide another health benefit for employees are the source of EDocAmerica patients. Employers pay a per use per month access fee, which usually averages less than $1 per use. EDocamerica.com has 350,000 eligible users – more than 1 million including family members, who are eligible to use the service.

Dr. Smith and his team are discriminating about what they can and cannot do. What they can do is “prescribe information” – give information, tell patients where to go to find information, link them to other relevant information websites, and tell them where to seek second opinions. What they cannot do is make diagnoses and prescribe drugs. Dr. Smith and his primary care crew say many patients visit their site on multiple occasions, and follow-up visits are welcomed.

Dr. Smith says the whole experience of communicating with patients from these employer groups has been gratifying. Because of email’s anonymity, patients share information they would not tell their personal doctors. Also, and this is a crucial point, employer groups and patients say the service saves money. A recent study of 1.2 million claims of those using the service against those who did not and found a 16 % reduction in fees, about $89 per claim, in users versus non-users.

Smith and his group have a partnership with revolutionhealth.com, and Smith’s blog can be found there in the list of Revolution Health bloggers who share insights to revolutionhealth.com visitors. You can also visit his blog at edocamerica.blogspot.com,

To conclude:

There once was a family physician named Smith,
Who sought to serve others through e-mail pith.
So he gathered one dozen primary care buddies,
Who were not stick-in-the-mud fuddy-duddies,
And they dispensed information forthwith.

HIMSS-07 Hangover

As everybody who is anybody in health care knows, the Health Information and Management Systems Society (HIMSS) supplies unparalleled leadership in health care for managing technology and information through its publications, educational opportunities, and advocacy – but first and foremost, through its annual meeting and exhibition gala.

That said: Hello out there, you health care IT crazies, those of you with a HIMSS-07 gala hangover. A hangover means either suffering from excess or carry-over knowledge from an earlier experience. HIMSS certainly had an excess of IT information, too much for an ordinary mortal like you to absorb.

But you loved it. As Oscar Wilde so famously said, “Nothing succeeds like excess.” This is especially true in health care information technology. And you will, no doubt, retain lessons learned from your week-long, in-depth immersion into IT health care at HIMSS-07. For the geeks, nerds, and technophiles among us, this was an exciting – perhaps over stimulating - event.

Wildly Successful

All reports indicate HIMSS07 was wildly successful, albeit overwhelming. I congratulate its organizers, who, in addition to transmitting the message that IT will go a long way towards saving health care, helped to resuscitate tourism in New Orleans.

More than 25,000 of you gathered in New Orleans the last week of February to hear hundreds of speakers, to meet thousands of contacts, and to view more than 900 exhibits. The advance slogan on the exhibits was,

“Innovations will happen. ‘What if?’ shakes hands with, ‘We can do that.’ And something new is born. Imagine that that happening hundreds of times day all around you.”

Sounds like an Innovator’s Dream to me.

Cyber Uber Alles

By now, in your hangover phase, you might think health care IT has the hardware, software, and brainware to make thousands of health care fixes, to repair and bridge most faults in our health system. and to coordinate it all, seamlessly, of course. Why not? Let’s face it. In many respects, you have just seen and heard the computer glorified as a cure-all of health care.

The Big Dogs

The big dogs – Steve Ballmer, CEO, of Microsoft, now on an acquisition binge to become the number #1 player in the health care space, General Colin Powell, USA (ret), a board member of Revolution Health, Inc., Michael Leavitt, Secretary of HHS, dedicated to the proposition of a national IT structure, Newt Gingrich, everyone’s alternative for President and self-styled IT health care guru, and Dr. Stephen Covey, everyman’s motivational speaker and author of Seven Habits of Highly Effective People – were there.

A Wild Idea --IT More About Cultivation of Ideas Than Technology

What a time you had! Garry Baldwin and Jim Molpus, reporting for Healthleadersmedia.com immediately after the conference, report the highpoint for them was a crazy idea – that effective health care IT might be more about ideas than technology.

“Thursday morning Harry Lukens, CIO of Lehigh Valley Health Network in Allentown, Pa., described how the community health system reaches out to the staff to develop new ideas. As Lukens pointed out, the session was not about technology, but rather the cultivation of ideas. For the last few years, Lukens has chaired a group called the “Wild Idea Team.” It sports a rotating membership of 18-25 people, representing all areas—and levels—of the organization.”

“Staff members bring ideas about ways to use technology to improve operations. The only rule for the discussion, Lukens said, was ‘no snickering.’ It’s a way to encourage participation. Ideas are vetted through a series of steps including informal evaluation, research, formal evaluation, and test. Most ideas do not make it to actual implementation. Nevertheless, the meetings are a way for the IS staff to stay in touch with their internal customers.”

“Lukens’ punched up his talk by using an interactive audience response system. Using a small handheld device, we were asked to vote on various questions, with the results tabulated and presented on his PowerPoint. Most in the audience had no formal manner of deriving technology ideas from the staff. Lukens uses the same technology at senior staff meetings to solicit feedback on strategic planning proposals. Allowing people to vote anonymously on ideas encourages more honest responses, he pointed out.”

Luken’s "Wild Idea" Team Should Surprise No One

Luken’s “wild idea” is engaging people in the front lines of the organization to submit ideas, and inviting feedback and haggling with them may be just as important, or more so, than deploying technology to improve the system.

That this wild and crazy approach works should surprise no one. After all, it’s just a swing back to Naisbitt’s High Tech/High Touch megatrend prediction – for every technologic advance there’s a counter-balancing human response.

It didn’t surprise me. In my February 25 blog, “Disruptive Innovation at Work: One Solo Doc, One Internet, One Room, One Year Later,” I described how one “Wild and Crazy” family physician, Gordon Moore of Rochester, New York, used the Internet to transform his practice into a highly cost-effective, quality-driven, patient pleasing operation.

Nor would it surprise Tom Peters, the Wild and Crazy management guru of “Ready Fire Aim! “ fame. Ever since Tom Peters and Bob Waterman burst onto the scene with their book Search of Excellence in 1982, Peters has become the guru on innovation.

Focus on People

In the management world, Peters and Waterman are known for setting forth these practices of successful companies – IT and non-IT, all focusing on people.

1. A bias for active decision making –“getting on with it.”
2. Close to the customer – learning from people served by the business.
3. Autonomy and entrepreneurship – fostering innovation and nurturing “champions.”
4. Productivity through people – treating rank and file employees as a source of quality.
5. Hands-on, value-driven – management philosophy that guides everyday practice—management shows its commitment.
6. Stick to the knitting – stay with the business you know
7. Simple lean staff –some of best companies have lean HQ staff.
8. Simultaneous loose-tight – autonomy in shop floor activities plus centralized values.

Peters’ Principles

Here are 26 of Peters’ current health care beliefs on how to fix the health care system. It’s a bit of a rant, but effective.

1. Fully utilize Physician's Assistants to do routine work in a timely fashion. ("Doc in a Kiosk" at Wal*Mart is great!)
2. Maximize Outpatient Services!
3. Short hospital stays work!
4.Support home care to the max. (E.g., "Declaration of Independents"—Beacon Hill/Boston)
5. STOP THE 100K+ NEEDLESS DEATHS—much/most of the "quality stuff" is eminently fixable. (Don Berwick for President! AHA for Hall of Shame!) (Strong, vicious insurer incentives!!!)
6. FLIP HC 177 DEGREES TO EMPHASIZE PREVENTION & WELLNESS. ("Steps" are being taken but not enough. Med schools: Awful! Insurers: Little better. Support for appropriate-proven alternative therapies is an important part.) (HUGE INCENTIVES FOR EFFECTIVE WELLNESS-PREVENTION PROGRAMS-MEASURABLE SUCCESSES.)
7. "Boomers" will determine HC's (very different?) future. (They are from a different & demanding planet compared to yesterday's Oldsters.)
8. "Focus on Women." (It's my generic—and correct—rallying cry, and it applies to HC in spades, women-as-patients-with different-woes-than-men; women-as-HC decision makers at the "consumer"—and commercial—level.)
9. "Patient/Consumer-driven" may be a buzz phrase bandied about all to easily ... but it is true. (And changes the game.)
10. Reduce incentives for unnecessary tests. (Malpractice caps would help, though the issue is complex. Insurers-HMOs doing so-so on this.)
11. OUTCOME-BASED MEDICINE IS A MUST! (There is a long, long way to go!) (Measure until you're blue in the face!)
12. Science-based medicine is a terrific idea!! (Many-most "therapies" unproven scientifically, uneven in application when proven.)
13. Over the next 5-25 years, the Life Sciences Revolution will make the likes of the "info revolution" look like small beer. (Get ready.)
14. Radical increase in "best practices" utilization—inculcate in Med school!
15. Med school "revolution" imperative—outcome-based medicine, abiding emphasis on Wellness & Prevention, etc.
16. Get info to Patients! (HIPAA mostly good.—"I wanna see my records!") (Detailed hospital-by-hospital, disease-by-disease, doc-by-doc success records a must—despite controversy.)
17. Upgrade IS-IT in the entire system, starting with acute-care nstitutions. (Current grade: D-.) (Winners include: Indiana Heart Hospital; Inova Fairfax Heart Institute.)
18. Healtheon WebMD-like (if it had worked) mega-, integrated-info network will-should emerge. (A healthcare Google+?)
19. MOVE HEAVEN & EARTH TO IMPLEMENT ELECTRONIC MEDICAL RECORDS. NOW.
20. By hook or by crook, something approximating basic universal care , starting with kids—50 state partial experiments is a help; some are quite far along. ("Market-based" as much as possible—but this is far from a "perfect market.")
21. Deal with the enormous HMO "I want my doc" perception problem. (Fact: MARCUS WELBY, STATISTICALLY, AIN'T THAT GREAT A HEALER IN TODAY'S "HIGH SCIENCE" WORLD! Incidentally, same perception problem re Congress, schools. "My Congressman is great, Congress has 434 other crook-clowns." "My kids' school is good, the system is awful.")
22. Blitzkrieg of Patient/Customer/Citizen education (e.g., re "outcomes-based health care ," "Get the most for your health care dollar"). (Corporate cuts should motivate this.)
23. "Healing-centric"care supported. (E.g., Planetree model—reduces future problems.)
24. Emphasize front-to-back "customer care " practices—cuts waaaaay down on malpractice claims among other things.
25. Specialization in acute care works wonders, regardless of howls! (E.g., Shouldice/hernia repair.)
26. Shorten the FDA approval process. (Tom , age 63, wants the good new stuff and will accept associated risk; so will most boomers-geezers.)
From Peters to Reece to Bullets
As you can plainly see, Peters stresses IT as it applies to people. Here’s my take on what he said.
• Delegate people other than doctors to deliver care.
• Serve patients in decentralized outpatient and home settings.
• Cater to women and baby boomers.
• Measure providers’ performance.
• Use specialists in hospitals.
• Cover people’s every insurance need.
• Engage and educate patients at every level.
• Ease, facilitate, and shorten patient care.

No Reason to Go On

I could go on.

But I don’t need to. You’ve been to HIMSS-07, and you’ve heard it all.

This year HIMSS was wild and crazy.

Just wait until next year!

Life Line Screening: An Example of an Innovation that the Public Wants and Will Pay For

In my last blog, I cited Peter F. Drucker’s comment that the key to a successful innovation is one that customers want and will pay for. This will become increasingly important in consumer-driven health care. In this new environment, patients will pay more out of pocket, will take more responsibility for their health, and will seek moe value for their dollar.

No Better Example

I can think of no better example of a successful innovative company in the health care field than Life Line Screening, headquartered in Cleveland, Ohio. It operates in 48 states and has teams of nurse and other professionals riding in more than 100 mobile vans to conduct screening clinics. These clinics feature two basic technologies: non-invasive ultrasound to screen for carotid artery disease, abdominal aneurysms, peripheral vascular disease, and osteoporosis; and blood tests to screen for diabetes and coronary risk (lipid panels and C-reactive protein).

Marketing

Life Line Screening markets their services by local and national media and sets up appointments for screening sessions in local neighborhoods, places of worship, and community and senior centers. The charge is $129 for four ultrasound vascular screening and $45 or less for the blood tests. Groups of well-qualified bck-up physicians interpret results, help contact patients, and refer them to local physicians should something abnormal occur. The company continues to grow each year.

Patient Satisfaction

In my own circle of friends, I know of at least half a dozen who get screened each year and who consider the screening an annual not-to-miss ritual well worth the price.

Why is Life Line Screening so successful? I think the reasons are quite simple.

• It’s personal -- Who among us hasn’t known of someone who died or been incapacitated by a sudden and unexpected stroke, heart attack, ruptured abdominal aneurysm, fractured hip, or has suffered the ravages of diabetes?
• There’s something magical about directly visualizing a vascular lesion in time to so something about it.
• It answers the fundamental question asked by admirers of innovation: “Now why didn’t I think of that?”

Readings on Innovation from The Daily Drucker (HarperBusiness, 2004)

Prologue: From time to time, I will reprint a daily entry from Peter Drucker’s book, The Daily Drucker. These entries may serve as an agenda item for physician entrepreneurs who seek to create a new company or introduce a new service. In his March 2 entry, Drucker makes this salient point about a successful innovation,, “Do customers want it and will they pay for it?” In tomorrow’s blog, I will give an example such an innovation.

Test of Innovation

2 March

Measure innovations by what they contribute to market and customer.

The test of an innovation is whether it creates value. Innovation means the creation of new value and new satisfaction for the customer. Yet, again and again, managements decide to innovate for no other reason than they were bored with doing the same thing or making the same product day in and day out. The test of an innovation, as well as the test of “quality” is not “Do we like it?” It is “Do customers want it and will they pay for it?”

Organizations measure innovations not by their scientific or technological importance but by what they contribute to market and customer. They consider social innovation to be as important as technological innovation. Installment selling may have had a greater impact on economics and markets than most of the great scientific advances in this century.

ACTION POINT: Identify innovations in your organization that are novelties versus those that are creating value. Did you launch the novelties because you were bored with doing the right thing? If so, make sure your next new product or service meets your customers’ needs.

Seven Sources of Innovation: A Devastatingly Brief Review with Concrete Examples

There are seven fundamental sources of innovation,
of which practicing physicians should have knowledge.
These innovations offer a reference framework
that may lead to a better and more balanced life
for doctors, patients, and the health system too.
There is always a better way to do things.
It is never too late
to innovate.

First is the unexpected --
The unexpected success,
The unexpected failure,
The unexpected outside event.
This innovation may be something as simple
As your patients spreading by word of mouth
that you see patients on time,
or they get their money back.
Or it may be giving patients access
to interactive online videos
to have and to hold,
to download and review again and again,
and to share with their families too.
The videos explain exactly what to expect
ror a surgical procedure or devices, techniques,
and methods to control your chronic disease.

The unexpected may be something as simple,
as patients giving their personal histories online.
When guided by a well-designed clinical algorithm,
patients tell their own stories on their own time
from their own uniquely personal point of view.
No one knows their symptoms better than they.
All patients need is a little guidance and direction
to channel their story into a coherent narrative.
by so doing doctors can document the exchange.
and save time and create a record,
reference letter and a claim document
for themselves, payers, and patients.

Second is the incongruity
Between realities as it actually is,
and reality as it assumed to be or “ought to be.”
Call this ‘disruptive innovation,” if you wish.
Maybe all things “ought to be done” in hospitals.
The incongruity is patients prefer things be done
in free-standing ambulatory care centers,
maternity centers, geriatric centers,
or better yet in their own doctor’s office,
with more time with their doctor,
with nothing between them and him or her,
but a feeling of a deep personal relationship,
or best yet in the comfort of their homes,
far removed and remote from hospitals.
Homebound patients prefer to have
vital signs, weight, and complications
monitored from distant audio-visual devices,
initiated abd controlled by themselves
from to their own beds in their own home,
rather than traveling to
some distant ER, office, or hospital.


Third is the recognition of process need.
There often needs to be changes in how we do things.
Examples of this innovation are rapid access scheduling,
seeing patients on the day that they call,
or rapid methods of patient evaluation,
as practiced by California Emergency Physicians,
or by consolidating receptionists, secretaries,
registration clerks, paraprofessionals, specialists,
laboratories, physician therapy units, pharmacies,
and high tech imaging and treatment devices
into one building separate from the hospital
in a facility known as a Big Box,
owned by docs, hospitals, and investors.

Fourth are changes in industry or market structure.
A prime example of this is managed care.
Managed care is negative for most practicing doctors.
It makes them quasi-employees and mere technicians,
subject to repeated review for utilization patterns,
to systematic reimbursement reductions,
to humiliating, frustrating, and costly claims rejections.
For other doctors with business ambitions,
managed care is a positive, fateful event,
a chance to become overlings in the suprastructure,
rather than underlings in the infrastructure,
to be the hammer rather than the nail.
It prods some doctors to seek greener pastures.
Managed care jobs prompt them to form
and to lead integrated groups and hospitals.
Doctors become a hybrid that has crossed
the Great Divide called physician executives,
who creates guidelines, best practices,
and quality indicators.
to maximize health
and minimize disease.

Fifth is demographics or population changes.
Who would have dreamed demanding baby boomers,
would have sought to stay and look young forever:
would have striven to have their knees and hips done
in middle age to compete as weekend warriors;
would have insisted on having Botox injections,
tummy tucks, face lifts, eyelid lifts,
nose jobs, neck smoothing, and collagen injections
to hide the relentless advances of aging and living;
would have undergone a barbaric procedure
known euphemistically as liposuction.
Who would have thought a movement
Deemed consumer-driven health care,
would give health consumers freedom, choice,
and incentives to rate hospitals and doctors?

Sixth are changes in perception, mood, and meaning.
Who would have imagined disease management
would transmigrate quickly into wellness management,
that smoking would be verboten everywhere,
in offices, bars, public places, inside cars and homes,
transfats, whatever they are, would be banned
every café, restaurant, and eating establishment,
obesity would make you an employee non grata.
chubbiness would replace smoking as a social No-No.
fatness would be the leading cause of diabetes,
and be held responsible for a host of other diseases,
and would be tied to poverty.
and even to the fate of the human race,
and decline of Western civilization?

Seventh is new knowledge, scientific and nonscientific.
Who would have thought that someday, somehow,
medicine would replace every organ save the brain:
would deploy stem cells to regrow spinal cords,
brain cells, Islets of Langerhans, and
even repair damaged hearts, and may be cure disease:
would use drugs would inflate a certain organ:
would personalize cancer treatment in such a way,
as to turn it into just another manageable disease:
would “virtually” view your bronchial tree or GI tract,
spotting those tumors without intrusive orifice probing?
Who would have thought that someday holistic support -
meditation, hypnosis, prayer, laying on of hands,
vitamins, herbs, roots, spices, and weird concoctions,
would be as important to patients as scientific advances?
Who would have thought patients would need gurus and poets,
just as badly the rest of us need nerds, geeks, and techies?

But how do you tap these seven sources of innovation
First, form an innovation team inside your practice.
Second, have your team meet frequently.
Third, name a nurse as Chief Innovation Officer.
Four, ask: How can we do things better?
Five, ask: How can I, the doctor, do things better?
Never, never, get discouraged or distraught.
There is always gloom for improvement.
And always remember.
Even come December,
it is never too late
to innovate.

References

1. Drucker, Peter, Innovation and Entrepreneurship, Practice and Principles, Harper and Row, 1986

2. Reece, Richard, Innovation-Driven Health Care; 34 Key Concepts for Transformation, Jones and Bartlett, 2007.