Monday, January 30, 2012

Care Innovation Summit (Jan 26, 2011 in DC)

I was one of 1200 "healthcare innovators" attending the annual Care Innovation Summit last week, sponsored by CMS, the West Wireless Health Institute, and Health Affairs magazine.  The day started with a fantastic keynote by Atul Gawande, MD, and then there were assorted panels talking about healthcare innovations across the US. 
My thoughts and reflections on the day:

First, it was a good use of time.  It is hugely important to be able to hear innovation stories, and it is important the providers, industry, and government are all sharing with each other and trying to figure out this mess we call a healthcare system.  Additionally, the networking is always fantastic at a place like this.  I was able to see some old friends like Ted Eytan (Physician Innovator and awesome blogger), Margaret Laws (CHCF), and Carleen Hawn (Healthspottr), as well as meet some new friends who do great blogging, like Andre Blackman (Pulse and Signal) and Dr. Joseph Kim (Medicine and Technology).

Second, Gawande's keynote was really great - how can a surgeon be such a good writer and excellent speaker?!?!?  He focused a lot on the importance of creating easier systems which cost less and deliver all the appropriate care to as many people as possible. A few comments he made which stood out:
  • Healthcare Costs are Killing the American Dream.  The "typical" US family has seen almost all of their increase in take home pay in the past decade go to paying for their healthcare costs. 
  • We need Automation and Teamwork.  The complexity of healthcare is increasing exponentially but we have not really altered how we deliver care - one physician at a time.  In the past "2 generations" (about 100 years), we have expanded to over 13,000 known conditions, 6,000 meds, and 4,000 types of procedures - physicians have to know all these and then deliver them to every single American - not exactly efficient (and rarely consistent).   In other words, "We need Pit Crews, not Cowboys".  Every other industry has learned how to automate and task shift… it's time for healthcare to do the same!   [Side note... I think this is so important for the future of healthcare - that it is the basis of a new company I helped create in the past year... more to come later]
  • We need better Data!  I love the analogy he gave… He said, "the way we currently provide data is like driving your car, but when you look at your speedometer, all you see is the speed of other cars from 4 yrs ago." We need to have real time data, specific to our needs!
  • The Best Places Act like Systems.  He noted these three key skills are needed:
    • The ability to recognize Success vs. Failure (i.e. need up-to-date data which is focused on a specific issue).
    • The ability to identify failures and then devise solutions for them… he of course pointed out that you should consider Checklists to help organize the "best care".  I agree!
    •  Make solutions easy to implement.  Keep them simple and cost-effective, and recognize the importance of consistency and teamwork.
Third, the government folks said that they know we have to become more innovative.  Dr. Richard Gilfillan (acting director of the CMS' Center for Medicare and Medicaid Innovation) said, "We need to decide now whether to make the commitment to adopt innovation that will fundamentally change the way we operate, change the way we deliver care, change the way we think about these organizations that we run. This is not an abstract notion; this is a very concrete question that each of us will have to answer."

Marilyn Tavenner (acting administrator for the Centers for Medicare & Medicaid Services) highlighted a variety of innovations, and expressed urgency in pressing forward with the “triple aim” goals of better individual healthcare, better population health and lower costs called for in the health reform law.

As a reminder, the summary of the Healthcare Reform law essentially comes down to four things: 
  • Value: improve quality and cut costs  (and the part that is TOP on the mind of everyone)
  • Access
  • Insurance reform
  • Medicare improvements
And the Triple Aim (as defined by Dr. Berwick) is:
  • Better care (at an individual level) - including the STEEP criteria (Safety, Timeliness, Effectiveness, Efficiency, Equitable, Patient-Centered)
  • Better health (at a population level)
  • Lower costs
CMS also recognizes that the only way to do all this is for government and payors to better align incentives (hence the experimenting with ACOs and other reimbursement changes).  And as Todd Park (CTO for CMS) said, do anything they can to help America's "innovation mojo" heat up to start solving problems (such as by promoting the challenges below). 

Fourth, they released a series of private-backed Challenges throughout the day.  ONC posts these challenges at  Here are the ones announced at the Summit:

Fifth, they had a variety of payors, disease management companies and providers talk about "innovative programs".  Health 2.0 blogged on some of these innovators, and here are two that stood out to me:
  • The WellPoint "Care More" model focuses on the 15% of patients which account for 75% of costs.  "Extensivists" work with PCPs to provide early and quick intervention (e.g. patients see the Extensivist clinic a few times a year, in addition to the PCP).  This model also uses a host of other providers as well (e.g. home care, social workers, dietitians...) to create a fabulously deep and rich team for these patients.
  • ChenMed is a provider group which focuses only on complex elderly patients.  Their mantra is "Coordination, Collaboration, Convenience, Compliance".  They succeed because they limit MDs to just 350-400 patients and build a whole system around these patients.  

So while these are both great programs, they also represent the weaknesses in the conference:
  • The majority of presenters focused on Medicare patients - understandable since that is of utmost interest to CMS… but there is much to learn with younger patients too.  Additionally, CMS must realize that poorly controlled younger patients will wind up in their lap eventually!  We have to somehow integrate CMS with the private insurers in some way to keep them both aligned.
  • The majority of presenters said they achieved some quality benefits by focusing a high amount of care on the "most complex 15%" of patients.  On one hand, this is great stuff - and important to learn how they did it so it can be replicated.  On the other hand, it should not come as a shock that expensive heavy lifting on those folks improved outcomes… were these innovations or simply sound logic?  Are they reproducible?  And did they cut costs (e.g. what was the ROI)?  

Additionally, I think a key quote of the day came from Aetna's CMO when describing a program they implemented to help patients after a heart attack. He said, "we gave them free meds after an MI, and compliance was still only 49%!"  So whatever we do we better make sure it is "easier" for patients than their current lives... because behavior change is really hard!!!

And one other great quote came from a nurse who was talking as a patient, knowing she was dying from cancer.  She did her research and chose to not try end-stage treatment that would hurt her quality of life and only possibly give her a small amount of extra time.  She reminded us not to "force" care onto everyone, for as long as someone has been educated, "There are no wrong choices, only informed choices."

Finally, how about some more IT Innovations?
We heard how IT could help collect, analyze and display data… which could be used to find problem areas or identify high risk patients (e.g. predictive modeling).  We even heard how the Archimedes Model can help predict the outcomes of various interventions.  However, we did not hear how IT innovations could allow for better economies of scale (via automation) and easier spread of improved processes.  My theory is that we use IT to help automate the care for the 85% of patients which are "healthy and stable", so that the high touch care for the complex 15% can continue.  I plan to do my best to support companies that fall into either of these buckets! 

Saturday, January 14, 2012

Welcome to 2012!

Wow… I am officially in awe of all bloggers who can post once a day, once a week or even once a month at this point.  I have clearly fallen off the horse - but am saddling up again for what looks to be an amazing 2012!   Yeah, I've been a bit distracted - helped start up a new HIT company (more to come), am working on a book highlighting the intersection of HIT and Innovation, and am juggling all the regular doctor and CMIO type of things.  BUT - no excuses… I've got to find some time to get my thoughts down!
I actually have a couple of blogs half-written in emails to myself, but I'm going to start with something more current… my take on various stories from one of my favorite blogs - HISTalk.  In their recent blog, they mentioned the following three stories (among others), and I thought each had some major importance so I want to highlight them and give my 2 cents:
First, Meaningful Use (MU) Attestation
CMS has provided the database for the statistics on numbers of physicians who have currently attested for MU.  Modern Healthcare did a nice breakdown in their story on it:
·    For Ambulatory:  Epic was the EHR of choice for 6,045 physicians and other eligible professionals, grabbing a 28% market share of the eligible-professionals segment, a slice larger than that of the next four vendors combined.  Those others in the top five, in rank order, are eClinicalWorks, 1,847 (9%); Allscripts, 1,449 (7%); Athenahealth, 1,158 (5%); and Community Computer Service, 999 (5%).  These top five vendors claimed 54% of the market of early adopters and meaningful users.  The top 10 vendors also claimed 71% of the incentive payments thus far.  But it's still a wide-open market.  The database lists 217 EHR vendors as having products that had been used successfully by at least one eligible professional to either achieve meaningful use or receive incentive payments under Medicaid.  Of those 217 developers, 131, or 60%, had 10 or fewer installations.
·    For Acute Care (Hospitals):  Epic also led among hospitals that received federal incentive payments for using a complete EHR, but the privately held company was not nearly so dominant in this indicator of the hospital IT market as it was in the EP segment.  According to federal data, there were 627 hospitals that have been paid using complete EHRs developed by 22 different companies or organizations.  Of them, 165 were Epic customers, 26% of that niche.  Ranked second was Computer Programs and Systems, commonly known as CPSI, used by 140 hospitals (22%), followed by Cerner Corp., 71 (11%); Healthland, 54 (9%); and Meditech, 47 (7%).

Mr.HISTalk said the following:  Here’s a point/counterpoint issue to mull over.  Inga and I disagree on the value of CMS’s attestation statistics.  Inga thinks the percentage of each vendor’s customers that have attested is a good benchmark, so she did lots of spreadsheet work to compare vendors and to assume that varying percentages among them must be reflective of product capabilities and ease of use in meeting Meaningful Use requirements.  I said the information is useless for that purpose since it’s more reflective of unmeasured customer demographics and buying criteria than anything else and that it would be wrong (not to mention statistically indefensible) to use the CMS figures to infer that vendors with a higher percentage of successfully attested users have a better product for earning Meaningful Use money.  Feel free to take sides.  One thing’s for sure: vendors who massage the data into slick marketing collateral won’t be footnoting their handouts with statistical disclaimers.

Here was my response:  I'm siding with Inga on this Point/Counterpoint… although the numbers are not perfect - they should provide value in two ways:

1. Totals. A general idea about the total number of real EMR users.  I’m sick of the vendors each claiming to have 50-100K users.  Sorry - there are only about 600K total active doctors… and only 25% using EMRs – so you are all splitting about 150,000 docs at best right now.  Although this initial data is a good start, I think very soon we will get a much better idea of how many docs are attesting with each vendor (since many are waiting until end of 2011) and then at least the general proportions will be easier to assess… will it be EPIC with 30%, and the next tier of 5-6 vendors at 5-10%, and then 210 more with under 1% each… or will we see a surprise pop up somewhere?!??!

2. Successes.  Fair enough – it is possible some EMR vendors will have a higher percent of attestations because they are better at implementation, etc… but hey - that’s OK, I think that is a key indicator too… and am fine if that “biases” the numbers.  But they are still valuable.

Second, Most Online Diabetes Management Tools are Ineffective
CMIO Magazine did a nice summary of the JAMIA study.  It turns out that over 75% of the time - the tools were NOT clinically useful or usable (or said another way- they were only useful and usable 25% of the time).  But perhaps more importantly was the second finding which is that patients just don't use these tools consistently.  Hey - that should be a surprise!  Yet it may shock or offend some in the "consumer empowerment" community who keep saying patients want more tools to use online.  While I think a subset do want these, it is just not the majority.  Unfortunately, the reality is that any tool or business model that relies on behavior change is a really tough sell.  Patients have shown for a very long time how resistant they are to change, and just having a website or app telling them what to do is not going to make that magically happen.  I do look forward to the next slew of websites claiming to have that "secret sauce" that will make patients change (e.g. games, rewards, social interactions), but think that the vast majority of folks who try to crack that code don't fully understand human behavior, especially as it relates to health.  It is much more complex than buying stuff online, banking and Facebook... but I do think we are getting better - and a well researched article like this will help us continue to move in the right direction.
Finally, "Smart Contact Lenses Keep Eye On Your Health"… Sensors are here baby! 
This news story asks "What if the lenses could look inside of you to diagnose, monitor and even treat disease? Sound far-fetched?  Well, it may not be too far away… The new generation of contact lenses is being called “smart lenses”, and they are packed with circuits, sensors and wireless technology – all designed to "keep an eye on your health".   It is indicative of a big and growing trend towards ubiquitous biomedical devices, especially involving sensors, which we will be hearing more and more about in the months and years to come.   Of course, it pairs well with the other big trend around big data - because this many sensors are going to need some major analytics to make them useful. 

Bottom line - there is so much amazing change and innovation going on in healthcare, cannot imagine a better industry to be in for the next few decades!!!