Monday, January 31, 2011

What Motivates us? Autonomy, Mastery and Purpose.

My friend Shelly posted a great video the other day entitled "Drive: The surprising truth about what motivates us", (video is below).  It's a fun, quick breakdown of Daniel Pink's book of the same name, which illustrates the hidden truths behind what really motivates us at home and in the workplace.   He starts out by laying this on us: "Our motivations are unbelievably interesting and the science is a little freaky! We are not as predictable as we think."

What really motivates us?  Once basic money is off the table (i.e. get enough to buy the basics), there are really three main things that drive us:

1. Autonomy:  We like to be self-directed.  Pink says employers should realize their employees probably want to do something interesting, they just need to get out of their way.  

2. Mastery:  It is fun and satisfying to get really good at something (i.e. learning the guitar, working on open source software).
3. Purpose:  We want to feel we are doing something important with our lives. Additionally, when the profit motive is not aligned with the purpose motive, bad things happen - a common problem in healthcare!

I think these apply very well to a physician's life, and explain why we will push ourselves very hard - we enjoy our autonomy, we enjoy mastering our skills, and our high level purpose is fulfilling.   However, what we don't like is when others try and tell us what to do (i.e. insurance company, poorly designed clinical decision support), when we are told to master something we don't particularly enjoy (i.e. not all doctors love EMRs - especially when they are really hard to master), and when we start feeling like our purpose is to make someone else money instead of focusing on patients.  

As for patients, I think this theory helps explain why we fail so often at helping them make significant lifestyle changes.  They need to feel they are doing it themselves (autonomy), they need to find something they enjoy mastering (a lot of people don't like exercise), and they need to see a tighter link between their actions and their ultimate "purpose" (which is likely to be healthy).

So as we talk about further implementing EMRs, expanding insurance access, reforming reimbursement schemas, and changing the very nature of patient care... let's remember both patients and physicians are still human, and will be driven by these age old motivations.  In other words, when making a change... think deeply about how you can best align autonomy, mastery and purpose - and you will clearly improve your chances of success!

Saturday, January 22, 2011

DC Hearings for Meaningful Use

I went to DC earlier this month to speak at a governmental "hearing" about Meaningful Use.  Since the Feds are about to spend up to $40 billion on creating incentives for EMRs - I give them credit for wanting to make sure they hear as early as possible if there might be problems with their program.

I blogged about my experience at the HISTalk Blog, so full details are here:

For those who just are looking for a quick summary, here you go:
ONCHIT's Implementation Committee wanted to hear from Eligible Providers (EPs) and Hospitals about their early experience in preparing to meet MU requirements for this year. 

The good news is that this bill has indeed "stimulated" many organizations to move forward with various upgrades and focus on how to produce quality reports from the data in their EMRs.  But mostly we heard about the challenges:
• This is hard. It’s not impossible, but it’s a higher bar than many had anticipated because the requirements are not simple, nor are they fully explained.
• Time crunch. There is a very tight time frame between the release of the requirements, embedding them into EMRs, the "rollout" of the new EMRs, and the updating of workflows and reports to ensure users are actually meeting the MU requirements.
• Resource crunch. This is often a zero-sum game with resources.
• We need more flexibility. Not every practice is the same, and requiring 100% mandate of every requirement is not reasonable.
• Functionality is not the same as usability. An EMR vendor can get MU certification for their functionality whether their usability is great, good, or poor. Fortunately, the government is starting to look into usability requirements for the certification process, so let’s hope they follow through on that sentiment.
• Standards. "We’d rather have one bad standard we can work with than three good ones without a clear winner." On the other hand, we should make it clear we do NOT want the government to make standards about actual functionality – we can and should be creative in that domain.
• The cost of implementing MU may often be more than the actual monies themselves, when you factor in costs for various software upgrades, consultants, and change management.
• Certification requirements don’t always exactly match MU process requirements. Someone has to keep a better eye on this.
• Communication with CMS and ONCHIT has not been easy.
• The result of most of the above is that the biggest and the best are struggling with MU… so you have to wonder, how much harder will it be for others?

It has been interesting that this is in stark contrast with recent ONCHIT announcements about a recent survey showing that the majority of doctors plan to apply for MU.  However, let's be serious - most docs don't even know what MU means, and less than 25% even use a "basic" EMR (and under 10% use an "advanced" EMR).   So if a doctor gets asked, "Do you plan to apply for free money from the government for using EMRs in the coming years?"... it should not be a shock that most will say, "Sure, I'll give it a try."  

I know ONCHIT is trying to keep an optimistic view here, but I wished they spent some time at these hearings listening to real world users and less time crowing about a survey asking a hypothetical question.  In fact, no one from ONCHIT actually came to these hearings - even though they paid for people from all across the country to fly in (to be fair and balanced, someone from ONCHIT did listen on the phone during the morning session, and the Committee did summarize and report to ONCHIT later on).

I think we all agree that ONCHIT's goals are noble, but if they don't get feet first into the reality of the situation, they will have a hard time getting there - these hearings were a good step in the right direction, and I hope they continue to keep their ears on the ground and make adjustments as appropriate.

Relevant Links
- Full details and testimonies from the hearings
- Review of the different types of ONC Certifications

Sunday, January 02, 2011

Health Innovation in 2011

This is going to be a big year - healthcare needs more change and innovation than ever!  So one of my resolutions is to do more regular blogging.  I will likely move to shorter blogs about news stories of interest, with a plan to distill them down to points which will be relevant to those interested in promoting innovative thinking and action in healthcare. 

I'm going to start with two new stories that are more related than one might think - one on healthcare value, the other on snow removal.

How Measuring Outcomes Drives Innovation
I just read Michael Porter's latest NEJM essay entitled, "What is Value in Healthcare?".  The key points are:

1. We need to base our reimbursement system on Value (Outcomes/Cost) not Volume.  In 2009, Porter described this in more depth in his NEJM article "A Strategy for Health Care Reform — Toward a Value-Based System".

2. Measuring real outcomes is critical (what really happens to the person, not simply their lab values or process followed).  For example, for a diabetic - real outcomes are whether someone loses their sight, needs to go on dialysis or has a heart attack (not what their HbA1C value is and how often it is checked).   He defines these in an "Outcome Measures Hierarchy" that involves three tiers: Tier 1 (Degree of Recovery), Tier 2 (Time to Recovery) and Tier 3 (Sustainability of Recovery).   This spectrum is what we really care about and encompasses both short and long-term outcomes, as well as "cycle time" (how quickly one gets to recovery).
3. The main purpose of measuring actual outcomes is to enable "innovations in care".  He describes how measuring, reporting and comparing these actual outcomes are what allows us to think and act in innovative ways. 

Dr. Thomas Lee follows up on Porter's essay with his own complementary one:  "Putting the Value Framework to Work".  He says, "When measurement is oriented toward what happened to patients instead of what services were performed, interesting challenges and opportunities arise."  For example, he notes that their typical PCP reports included data on number of office visits and RVUs, but not on the number of ER visits and hospital re-admissions, nor on the cycle times for how quickly discharged patients are seen in follow up clinic.  Dr. Lee also notes that "just the collection of such data requires organizational change and the weakening of walls between our silos", (which I assume he means is a good thing!).   He notes that his system (Partners) is currently working on creating "value dashboards" for issues such as stroke, diabetes and colon cancer.  They will identify "pause points" in patients care and define what should be routine at those points via checklists.  That is basically what we have been developing with our Process Checklist System (we call them "Pathways") - for things like new diagnoses of Hematuria, Afib and Cancer - so I am a big can of that concept!

Paying plows by inch, not hour, can save a city’s snow budget (link to story)
The second story which caught my attention was an NPR interview I heard with the Mayor of small town in Massachusetts... and how they saved time and money by creating a value based system for snow removal.  Apparently, the typical reimbursement mechanism for snow removal has been to pay for the amount of time to remove snow ("hourly rate").  Thus the incentive for truckers has been to go slow so they can charge more.  The Mayor of Quincy changed the incentive to paying by the inch.  The result is that they saved money AND the snow was removed more quickly!   Yep - just common sense, and something that I'd like to see more of in the healthcare system as well!!!