Saturday, September 26, 2009

Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes

The California Healthcare Foundation (CHCF) just put out a new paper on Innovation Centers- it’s a nice overview of what is happening out there formally, and ideas on how they can be expanded. The paper highlights 9 innovation centers/organizations across the nation:
- Kaiser's Garfield Health Care Innovation Center
- Vanderbilt's Center for Better Health
- Mass General's Stoeckle Center for Primary Care Innovation
- Mayo Clinic's Center for Innovation
- Johns Hopkins Center for Innovation in Quality Patient Care
- Ascension Health
- Alegent Health
- Geisinger/Geisinger Ventures
...and the one I help lead: The Szollosi Healthcare Innovation Program (

Intro is below, full paper is online:

Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes
by Bonar Menninger
September 2009

Hamstrung by an increasingly complex, costly, and disorganized system of care, health care organizations are following the lead of the corporate world and embracing innovation as a way to overcome the seemingly intractable problems that have undermined U.S. health care delivery for decades.

Today's innovation centers — most of which are affiliated with large hospitals or health systems — range in scope from modest internal programs to large, formalized organizations with dedicated physical space, sizable staffs, and external clients. Key areas of emphasis include facility design, operational efficiency, optimized information technologies, improvements in the patient experience, and care quality.

Leaders at health care innovation organizations nationwide were interviewed to learn more about how the centers operate, the objectives they are pursuing, and some of the challenges they face.

The complete issue brief is available under Document Downloads below. Also available is a video presentation on the Garfield Health Care Innovation Center at Kaiser through the External Link below.

Tuesday, September 15, 2009

Joe Flower's "How to Mayo Up" and Innovation in business models

Joe Flower is a "healthcare futurist" and writes some great articles to promote and provoke thinking about what is ahead. In his recent article "How to Mayo Up" he postulates that a key success factor in creating value based healthcare is having an "integrated system" (ala Mayo, Kaiser, Geisenger, Group Health, etc) - by having both the health plans and physicians working together, they can create the right reimbursement models to align incentives with quality and efficiency... and foster oodles of innovation!

A segment of his article summarizes Clay Christensen's recent book, The Innovator's Prescription, extremely well. I think Christensen's idea are both logical and innovative, and this summary by Joe Flowers is as good as it gets:

Innovation in business models.
In The Innovator's Prescription, Clayton Christensen and his co-authors make a compelling argument that what is holding health care back from true innovation is a confusion of different business models within single institutions.

Porter and Teisberg, and Herzlinger, make similar arguments: Competition does not work in health care because of a confusion of business models. Put two health care systems in direct competition, and what they do is add services that are reimbursed well enough to make money, add specialists, jack up utilization as much as possible and avoid as much uncompensated service as possible. Done this way, competition between general hospitals and comprehensive medical systems helps drive the cost of health care up, not down.

Medicine comes in different flavors, Christensen et al. argue. Some diagnoses and some therapies have no settled pathway, and truly call for the intuition, experience and judgment of the best clinicians, ideally working in teams that bring different skill sets to bear on the same problem. Think migraines, depression, multiple sclerosis and most types of cancer. Call this "intuitive medicine." On the other hand, there are broken bones, strep throat, Type 1 diabetes, cataracts, and hip and knee replacements— conditions for which the diagnosis is certain and the clinical pathway quite clear. Call this "precision medicine."

These two types of medicine have completely different pathways to value, so we will never be able to find that value until we separate them, each with their own business model. Intuitive medicine calls for a "solution shop" model, in which the right resources are gathered to look at your particular problem. Examples are M.D. Anderson for cancer; National Jewish in Denver for pulmonary disease, particularly asthma; the Texas Heart Institute; or the heart and vascular institute and the neurological institutes of the Cleveland Clinic. Intuitive medicine must always be billed as "fee for service," as both the level of resources needed and the outcome are unpredictable.

Precision medicine, on the other hand, calls for a "value-added process" model, much like a factory. You do one thing over and over and get really good at it. The project is well-defined, the outcomes highly expectable, the variations well managed. Such processes can be bundled into products—from diagnosis through rehab, including imaging, pharmaceuticals and counseling—and given a price tag and warranty. They can be billed on a "fee for outcome" basis, as the outcome is fairly certain. On such a targeted basis, you can get rapid improvement and lower costs.

Christensen et al. cite Ontario's Shouldice Hospital, which is dedicated to hernia repair and does it as a four-day, inpatient process on a country-club-style campus—and still charges 30 percent less than the U.S. CPT 49560 outpatient hernia repair reimbursement. And U.S. hernia repairs average 10 to 20 times the Shouldice's 0.5 percent complication rate.

Examples of how EMR User Interfaces may look in the future

As I was putting up the post about "The Medical Record as Nutrition labels" - it reminded me of the "new" EMR User Interfaces I put together a few months ago (with the help of some very talented graphical designers).

First is a way to think of the problem list as a series of circles or boxes whose color and size each had meaning, and whose relationship to one another was made obvious. Here are two examples:

The next is a problem list that is even more fanciful in using graphical visualization to represent each diagnosis and its acuity and importance:

And finally, here are two views of how to pull all the data together to explain a patient with respect to their diagnosis of hypertension (i.e. one page that brings together meds, labs, tests, history, physical, and plan about a single disease entitity):

Sunday, September 13, 2009

What if the Medical Record looked like a Nutrition Label?

In one of my first posts, I talk about inadequacies of the EMR's user interface - a paper based approach that does not take advantage of either the power of the computer nor the artistry of information visualization. Around that time, my friend and colleague Dr. Ted Eyton ( told me about someone he had started following who was doing some cool stuff in this area. And she was not some high brow informatics type, simply an artist with a passion. Here is her story:

What if your spouse had a complex medical history and you knew that the standard "medical record" (whether paper or electronic) was simply inept at helping your healthcare providers get the full and complete picture of his/her health. What if you knew that it was full of an overwhelming amount of numbers and facts, was disorganized and inconsistent in its presentation and had many errors scattered throughout. What would you do?

If you are Regina Holiday (, an artist with a husband dying of kidney cancer, you use your talents to help others understand that there may be better ways to visualize medical information. Relatively easy ways to organize data and present it in a graphically pleasing and consistent manner such that the key medical facts are obvious to any healthcare provider (or even to any family member).

Regina has created a mural of her husband’s medical record that resembles the “Nutrition labels” we see on most things we buy in a grocery store. It is a great way to shock our systems in thinking that medical records don’t have to simply be a problem list or a free text narrative of what happened on one day from one viewpoint… take a look below and think how your own medical records might benefit from this type of thinking. Regina's husband Fred died this past summer, but her fight goes on.

Here is a video of Regina painting and talking about the mural and its meaning (note: it goes black after 3 minutes, nothing else comes on):

Tuesday, September 01, 2009

Meaningful discussion on Meaningful Use

I've been wanting to expand my comments on the meaningful use criteria for awhile, and has this piece posted last week on the HISTalk Blog:

Basically, it's my view of the criteria and proposed definitions - with some suggestions on how to help ensure the intent in a more realistic manner.