Friday, August 20, 2010

SHIP in the Harvard Business Review article on Healthcare Innovation

Healthcare remains one of the largest parts of the US economy, accounting for $2.5 trillion dollars, or about 17% of the GDP in 2009, which is estimated to rise to 25% of the GDP by 2025 (unless major changes are made).

So it is no surprise that mainstream business magazines will be writing more about healthcare innovation in the years to come. This month's issue of the Harvard Business Review (September, 2010) has an article entitled “Kaiser Permanente’s Innovation on the Front Lines”.

The first part of the article talks about how Kaiser funds an internal "Innovation Consultancy" group (led by good friend Chris McCarthy) whose focus is to develop "service line innovations" to improve the quality and efficiency of care, as discussed below:

The Innovation Consultancy takes on carefully chosen projects throughout Kaiser Permanente, which is based in Oakland, California, and serves the health needs of more than 8.6 million members in nine states and the District of Columbia. That’s a huge laboratory for tackling opportunities to improve health care practice. McCarthy and his colleagues pursue an expansive, service-focused version of innovation, not the conventional one that by definition excludes everything but new technologies or tangible products. Surprisingly little attention has yet been paid to this version. But, as Kaiser is discovering, the bucks are relatively few and the bang can be disproportionately big. Compared with costly, long-horizon, research-driven innovation, service-focused innovation can be done both rapidly and economically.

The second part of the article talks about how Kaiser’s Innovation Group helps lead the Innovation Learning Network (ILN) – a consortium of non-profit organizations who have banded together to learn about and share healthcare innovations. The innovation program I direct (the Szollosi Healthcare Innovation Program , aka SHIP) has been an active member of the ILN and was featured in this article. The author highlights our “Inflection Navigator” project as an example of the importance of open collaboration between institutions to create these “service line innovations” which focus on both increasing quality while also improving the patient experience. Here is what he wrote:

Care Coordinators
Lyle Berkowitz is a Chicago primary-care physician who also runs the Szollosi Healthcare Innovation Program, a charitable foundation that belongs to the Innovation Learning Network. Berkowitz has worked with the ILN on a process to help patients who’ve received a frightening diagnosis more easily negotiate the ensuing flurry of necessary activity: follow-up tests, visits to specialists, decision making about treatment and care. The process is called Inflection Navigator, because a diagnosis of cancer or serious cardiac disease, for example, presents the patient with a profound inflection point.

At such times many patients feel too overwhelmed to ask important questions or undertake important tasks. Inflection Navigator assigns to each patient a care coordinator, who explains, assists, sets up appointments, anticipates questions, and provides answers. The care coordinator sequences activities to minimize the inconvenience to patients and maximize the value of the time they spend with doctors. For example, a patient’s visit to a specialist might be scheduled only after the necessary tests have been done and the results can guide a recommendation. “It decreases the burden on both the patient and the doctor,” Berkowitz says.

It also bends the cost curve down. Care coordinators don’t have to be highly trained and heavily compensated. They depend on a database of medical protocols reflecting best practices for diagnostic procedures and the latest treatments for various diseases. This frees physicians to spend more time where their expertise makes the greatest difference. The process bends the learning curve, too. If, say, the standard treatment for atrial fibrillation changes, “the cool thing is I don’t have to go and try to educate all my doctors,” Berkowitz says. “Because it can take years to do that. All I have to do is change the protocol that’s already built into the system.” The physician makes the diagnosis and then hands the patient off to the care coordinator.

Democratizing Health Care
Lyle Berkowitz mans one corner of a small booth on the modest show floor of a conference and expo in Boston. The event is a joint production of the Innovation Learning Network and the Center for Integration of Medicine & Innovative Technology, a nonprofit consortium of Boston-area teaching hospitals and engineering schools. The proceedings might best be described as a festival for health care geeks. Berkowitz is busy explaining Inflection Navigator to interested attendees. The emphasis here is on sharing, not selling. No booth bunnies, blaring music, flashing lights, or branded tchotchkes, just conversation—enough conversation that superior listening skills are needed to hear above the din. The exhibitors have zeal in common. They want to make health care better, smarter, cheaper, and more accessible.

Chris McCarthy hovers and circulates. It’s the last day of the event, and he has the semirelaxed look of someone who has either dodged or dealt with whatever might have gone wrong and is finally surrendering to satisfaction. Sharing real-world evidence of what works—ideas, practices, protocols—exhilarates people like McCarthy and Berkowitz. To them, there’s nothing odd about 16 independent organizations coming together to improve more quickly than they could if they were left to themselves. It simply makes sense to spread improvement as broadly as possible. This is not the vision of health care that emerged in the grinding yet cartoonish debate leading up to the passage of what is now called Obamacare. It was easy then to imagine that the whole system was willfully committed to cruelty, greed, vanity, and ineptitude. Beyond the fray, however, creativity flourishes. McCarthy and others, by democratizing the methods of innovation, are democratizing health care, giving patients and non-physician caregivers a louder voice in designing the future.

Tuesday, August 10, 2010

Minute Clinics - Destruction or Inspiration

A poster at The Health Care blog recently pointed out that Minute Clinics (and similar) are seeing increasing number of visits while Americans are going to their doctor less... and wondered if this was the dawning of a new age (and sun-setting of an old one).

Here was the comment I posted:

What is old is new again... "quick care clinics" have come and gone many times over the past few decades - are they really the be-all and end-all answer this time? I think they have a role, but certainly don't solve everything - and their major benefit may be in making doctors think more innovatively about how they deliver their care for low complexity cases.

More specifically - let's start with the clinical perspective: there will be anecdotal stories of great convenience, but also those of horribly missed diagnoses. From an efficiency perspective, there will be wonderful stories of quicker access vs. going to the standard practice... but two things are critical to understand:
1. There are not enough NPs and quick care clinics to truly handle all the demand out there.
2. Practices aren't going to stay standard forever. Many are now doing virtual visits via phone or the web - and hey, that's even easier and more convenient than having to find a clinic with an NP and register there. So boom... the efficiency rod strikes right back at them.

Of course, the truth is that there is PLENTY of DEMAND right now, and not nearly enough supply, so everyone will be busy for awhile. But this is an important time for care providers to start rethinking how they deliver care, especially to the "easy, highly structured" cases (e.g. URIs, UTIs, as well as stable Htn, DM...) and hopefully we will start seeing more innovation in this model - thus freeing up doctors to have more time for the more complicated cases as well!

I wrote a more thorough review of all this back in 2007 when the same questions were coming up... check it out:
A Time of Change: New technology-enhanced care models may change everything. Will you be able to adapt?

Monday, August 02, 2010

DrLyle's Take on the Meaningful Use Rules

I wrote up some notes about MU last week and the folks at HISTalk published it - here is the link to that posting (as well as some interesting comments from others):
DrLyle's Take on the Meaningful Use Rules 7/30/10

And here is the text from that post, with links to resources on the bottom:

In mid-July, the government released the final rules on MU and EHR certification. I was actually at the perfect place for this — the annual meeting of AMDIS (Association of Medical Directors of Information Systems). So we had 200 CMIO-type docs and a panel of speakers ready to talk about this topic. HIT geek heaven!

From my bias of focusing on ambulatory EMRs, here is what I learned at this meeting from listening and talking to some very smart people on the topic and reflecting on everything the past few weeks:

Big picture stuff
MU Rules are reasonable. The government listened to the end users and decreased the expectations on the "Core Rules" (decreased the percentage of eRx required), while putting other rules in an optional "Menu" (i.e. choose five of 10). But be aware, anything optional you don’t do in Phase 1 will be required in Phase 2 in 2013 (i.e. you’ll need to do 10/10 from the Menu)… and they will likely think of more things to add by then.

MU Rules are still not a slam dunk. Even for mature users, there will be work that needs to be done. It is hard to believe that a non-mature user, or users without a lot of resources, will be able to easily accommodate everything.

The government seems to think this will really work well and we will see over 50% adoption by 2015. I would love that, but am less optimistic. Best quote I have heard is that MU incentives are like giving someone money to have a baby. You will have a baby if you want a baby. The money is a nice extra, but not the main driver. Change is hard, so I am hoping that while we keep asking vendors and users to add functionality, we consider how we can improve usability at the same time.

I do hope the government is at least working on a secret Plan B in case 2015 comes and we are only at a fraction of where we need to be (e.g. maybe they give money to innovation think tanks to figure out better EMR user interfaces). If you want to read more about the rationale behind having a Plan B, check out the great Kuraitis/Kibbe blog on this topic.

Per John Glaser, we need to think about MU not as a simple, one-time incentive, but rather as a stepping stone to bigger reimbursement reform. In other words, it helps groups create the HIT foundation for alternative care models and payment reform of the future (e.g. Medical Homes, ACOs). In that future, an EMR is no longer a competitive differentiator, but rather how we use our EMRs will be the differentiator (e.g. care efficiency and improvement, use of clinical decision support, secondary use of data, and patient engagement).

Some details that popped out at me
1. The denominator is now "unique patients" rather than patient visits. So if a patient is seen three times in a year, you just have to fulfill the rule at least once for that patient.
2. Scoring will be done on an individual physician basis, not on a group-wide analysis.
3. To correctly measure many of these details (e.g. give clinical summary to 50% of those who ask) we would need to figure out a way to keep track of who "asks". That seems like a strange request for structured data and certainly should not be what a doctor is spending his time doing. So either we need to make it an easy administrative chore or consider doing it for 100% of people automatically.
4. For patient reminders (for patients over 65), physicians can decide content and format. For example, we can decide to just do colonoscopy reminders and only do it via mailers to patients — it does not have to be electronic. The point is to just prove we can identify patients by age and communicate with them in some way.
5. Patient education. We need to figure out a way to document when we provide these handouts. Some EMR systems may have that built in, but even then, just for the handouts they have. What if I go online and print something else out? Or give them a special handout I have created? We may need to create a special patient education section to document this, but it is again more busy work for physicians (which I am not a fan of!).
6. EMR vendors are on the hook. They are required to ensure some level of MU reporting from their EMRs to get certification. The result will likely be that they will be spending a lot of extra time and money preparing their EMRs and then trying to get everyone to take those upgrades. They will then likely just certify the most recent version of their system.
7. EMR users need to upgrade, due to above point. It is unclear how all current EMR users are going to be able to quickly upgrade their systems in the coming 6-12 months. That takes a lot of planning, time, resources, and money. I wonder if users of "older versions" will band together to try and get their older versions certified, or if the vendor will help at all?

• The NEJM summary from Dr. Blumenthal
• A summary from Computer Science Corporation (CSC)
•  Full text of the MU rule from HISTalk
MU PPT Slides from CMS
* The HHS FAQ about MU