Healthcare Revisited Consider how healthcare should be... Mon, 13 Jan 2014 08:27:21 +0000 en-US hourly 1 What’s the difference between healthcare and Cinderella? Sat, 14 Apr 2012 00:33:36 +0000 more »]]> ;

Glass slipper

Healthcare and Cinderella

The US healthcare system is facing an eminent change in its business model. Over the last several decades, through poorly aligned reimbursement systems and convoluted, market distorting subsidies, the business of our delivery system has become the filling of hospital beds. Sure, as a group, healthcare is filled with people who want to provide quality care, help patients, and improve outcomes, but that’s not what we get paid for. The vast majority of money in US healthcare is made by filing hospital beds, and by shortening length of stay.

In just the last decade, there’s been an increasing awareness of how broken our system is. We pay 2-3 times more than any other developed nation, and we have very little to show for it. In terms of performance, the World Health Organization ranked the US system 37th in the world; just above Cuba and Slovenia, and just behind Costa Rica and Dominica.

With the increasing visibility of how broken our system is, and the increasing industry awareness of the fact that the business models that have led to this travesty must change, you would think that more delivery systems would be seeking to shift to a more progressive solution. In an effort to help communicate part of why we’re moving so slowly, I wanted to share an analogy.

Let’s start by imagining a healthcare delivery system, all dressed up in a ball gown and glass slippers. Sould a little silly? Stick with me for just a minute more…

For those of you without kids, I’ll give a quick recap of Cinderella. She’s at the ball, and she knows that she has to get out at midnight or things will go badly. She watches the clock, and at 11:59, she edges close to the door, but doesn’t worry about it too much. That’s because she knows that when the bell tolls, everyone else will still be busy dancing, so the exit path should be pretty vacant. She can make a clean escape, with minimal fuss.

OK, so maybe that’s a slightly over-abbreviated version of the original, but it helps make an interesting analogy to the situation that the US healthcare industry finds itself in. Except Cinderella’s situation was substantially better.

Now, as our delivery system dances around the ballroom of fee-for service, it’s become pretty obvious that, as with Cinderella, the Fee-for-service festivities are going to have to come to an end. There aren’t many people who still believe that the days of fee-for service will continue indefinitely, and at midnight, she’ll need to scoot out the exit and move on to some type of Accountable Care model of reimbursement. The problem is that in the healthcare scenario there’s no clock on the wall to provide an early warning before the switch happens. This lack of clarity on when the proverbial bell will toll makes planning an orderly exit much harder. The delivery system just doesn’t know when to start edging closer to the door.

To make things worse, there’s a second key difference. While Cinderella knew she was the only one who needed to sneak out come the witching hour, when the clock finally does strike at the Fee-for-service ball, and it’s clear to our delivery system dancer that accountable care is emminent, she’ll suddenly find herself surrounded by an entire industry of other exiting delivery systems, all needing to quickly make it out the door before badness befalls them. It’s not going to be a quiet scoot out the ballroom door. It’ll be more like a fire at a heavy metal concert. There’s a high likelihood of some fatalities. Some will be trampled as the mob rushes for the doors. Others will be too late, and won’t make it out of the building in time. There are some predictions that as many as 30% of hospitals will close by 2020.

Now, this all sounds like a fairly grim situation, and if anything, it seems like even if the exact timing for exit isn’t clear, there would be some tremendous impetus for delivery system CEO’s to start moving towards the ballroom door to help ensure that they are among the survivors. So, what’s the delay?

The final problem is that during our time at the ball, our dancing healthcare Cinderella has developed a tremendous appetite. She’s built lots of hospitals, which represent a tremendous capital investment, and an enormous operating expense. The finances of these lumbering systems make our ballroom dancer positively ravenous for revenues. To make things even more challenging, as it turns out, at this ball, the cake table is on the complete opposite side of the room from the exit. Under the current fee-for-service business model, there isn’t a good way to make nearly as much money keeping patients out of hospitals. To clarify, that means that every step towards the accountable care door is also a step away from the fee-for-service food.

And being hungry hurts.

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It’s NOT the patients’ fault! Stop whining and fix it. Fri, 13 Apr 2012 21:11:05 +0000 more »]]> Whining baby

Stop whining and make better tools!

Healthcare has to be among the whiniest of all industries. Can you imagine leaders in another industry blaming the consumer for not using their product? Can you imagine what would happen if a product director at GE, or Apple told his boss that the reason his product wasn’t successful was because of a problem with consumers? 

I can imagine it now, “Mr. Jobs, the product is perfect, just the way it is. The reason it’s not selling is because users are just too dumb to realize how good it is.”

It’s easy to see that response is whiny and lazy. They’d be lucky to get back to their desk before they were fired.

So why do we continue to put up with that mindset in healthcare? I recently read an Information Week article from Paul Cerrato titled, “Why Personal Health Records Have Flopped; It’s not a security, privacy, or data-sharing problem. It’s a patient problem“. In the article, he says that the problem with Personal Health Records is consumer apathy. That kind of thinking is no different than the ridiculous scenario we were imagining at Apple. Stop blaming patients, and put in the energy to figure out what they want and need!

Now Paul, just to clarify, I’m not endorsing Colin Evan’s belief that the problem is providers’ unwillingness to put patients in control of their medical data, either. What would a patient do with their medical data if they did have control of it? Medical data takes a lot of knowledge to understand and interpret, and the average healthcare consumer has about a 4th grade reading level (that means that half of them are actually reading below that).

What I am saying is that if we want to successfully improve the healthcare industry, we can’t be satisfied with blaming the patients. We have to take the time and energy to ask “why”. Why are people willing to spend twice the energy picking a TV that they’ll spend picking their doctor? Is it because they don’t care about their health? Personally, I have a much harder time believing that people don’t care about their health, and a much easier time believing that we’ve made crappy tools, that don’t adequately support consumers’ needs when it comes to the complex, confusing, and intimidating healthcare industry.

We need to know that we’re giving people access to good healthcare consumer engagement products that are functional, usable, and hopefully, even desirable. And to do that, we have to stop whining and recognize that it’s not the patients’ fault.

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Why Epic myChart is NOT a Personal Health Record Wed, 08 Jun 2011 00:26:46 +0000 more »]]> Epic Systems MyChartI’ve spent most of the day today listening to  conversations about Epic myChart. As I’ve learned more, it’s become very clear that myChart is a good set of tools. But I have to suppress my urge to correct people every time they call it a Personal Health Record. It’s not. Why? Well, let’s start with a definition. One of the best definitions  of a Personal Health Record (and one of the most widely accepted and authoritative) that I’ve seen comes from HIMSS (Healthcare Information and Management Systems Society). They define a PHR as being:

“Universally accessible and layperson comprehensible, used as a lifelong tool for managing relevant health information…  Owned, managed and shared by the individual or his or her legal proxy(s), [allowing patients or proxies to] receive data from all constituents that participate in the individual’s healthcare…, enter their own data, and designate read-only access to the ePHR.”

If we break that definition apart, there are arguably four key components to this definition:

  1. Accessible and understandable
  2. Shareable, portable and lifelong
  3. Comprehensive (contains all relavent data)
  4. Owned and managed by the patient

Now myChart has done a reasonable (but not ideal) job with the first component. Presenting a patient’s medical information in an online format in an easy to navigate tool, using patient friendly terminology is a huge step forward; especially for an industry that’s known for its cryptic “medicalese” language and unwillingness to provide patients with access to information. I’ll post again soon about what I think is needed in order to make more meaningful strides towards truly understandable medical information. For now, I’m willing to concede that myChart meets this criteria.

On to the second point. This one is a little more dicey for several reasons. The myChart tools do allow patients to share their information with others, but for all intents and purposes, you either share it all, or you don’t. That may seem like a minor issue, but here’s a functional example of the problems that this creates. In many states, children between the ages of 13 and 18 have a right to receive particular types of medical care without parental permission (e.g. birth control, treatment of STD’s, and some behavioral health issues). Because myChart sharing is “all-or-nothing”, we’re expecting to have to completely turn off access to myChart for patients in this age range, since there is no way to only share “non-protected” information with parents. In addition, because the myChart web tools are “tethered” to the Epic EMR, the information in myChart isn’t really portable. I can’t really bring it with me to another healthcare system that isn’t using Epic. This also limits the “lifelong” nature of the tool. I’ll be generous and give them half-credit.

Considering the third point,  comprehensiveness, Epic seems to have made some good initial progress around this with their Lucy and myChart Central solutions. This allows information from other Epic systems to be seen within myChart, but most of the “Care Everywhere” functionality is provider-centric. It gives providers a reasonable way to see electronic data from outside of Epic, but I have yet to see a good way for patients to consolidate their medical information from multiple healthcare systems in a single place. Unless you’re part of an HMO like Kaiser (and you don’t ever travel or get emergency care), there’s a very high likelihood that you are getting care from multiple helathcare systems. Until all that information can come together in one place, I think that half-credit on this is generous as well.

In regards to the final point,  owned and managed by the patient, this is where myChart really starts to fall down as a PHR. Patients are extremely limited in their ability to enter their own information into myChart. Patients can submit information to their provider for review, but only the provider is able to actually add information. For example, if I started taking a non-prescription medication (e.g. aspirin, herbals, prilosec, antihistamines, etc), I could send my provider a note that tells them that I’ve started takign that med, but if they forget to add it to the chart, or decided not to, I have no ability to enter it into myChart myself. This is another place where the functionality from “Lucy” is helping them to move forward, but myChart is still a far cry from patient owned and managed. Under the best of circumstances, this is another half-credit area, and it’s probably closer to a “zero”.

If each of these criteria are weighted evenly,  myChart would score just above a 60% as a PHR.  Now make no mistake, I’m impressed with the work that Epic has done. Its created a nice set of tools to begin the process of modernizing the patient experience. It allows patients to schedule clinic appointments and send secure messages to their providers, request renewals of your prescriptions and pay medical bills. It also gives you a limited “patient friendly” view into your medical record. That’s pretty neat, but it’s not a Personal Health Record (PHR). It is a small window that allows patients a controlled and restricted view into information that is controlled and used by providers. It’s a Patient Chart View.  By calling it something that it is not, we risk lowering the bar on  one of the most important patient enagement tools available – a true Personal Health Record.

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Defining telemedicine vs telehealth Fri, 29 Apr 2011 19:50:38 +0000 more »]]> Why do we bother distinguishing between Electronic Medical Records (EMR’s) and Personal Health Records (PHR’s)? I mean both of them are, at their core, just healthcare content management systems. Why do we spend all this energy distinguishing between them?

The obvious answer is that while the two solutions are certainly related technologies, they are designed to meet two very different needs, and are pointed towards two very different audiences. EMR’s are tools used to help clinicians manage and share content with other clinicians. PHR’s are there to connect with patients. Since this is such an obvious difference to anyone familiar with healthcare, why is it that we don’t bother to make the same distinction in the case of telemedicine vs telehealth?

There are two very different uses, two totally different audiences that these two solutions are directed at. By lumping them together, we’re failing to use either of them as well as we should. That means we’re doing a disservice to both groups of users, the same way we would be doing if we tried to lump EMR’s and PHR’s together and use them interchangably.

There is certainly some similarity between telemedicine and telehealth. They both use technology to remove the geographic barriers to providng healthcare services. Sometimes, they even use similar technology, but that doesn’t really matter because the technolgy is just a channel. In the end, what healthcare consumers are “buying” when they use either telemedicine or telehealth is the service and expertise on the other end of the line.

In healthcare, there are two different kinds of clinical services that can be provided; care delivery and consultation. Each type of service has a different consumer. When a patient comes to a provider seeking care, and we respond with diagnosis or treatment, that’s care delivery. In that situation, the consumer is the patient themselves. But sometimes, the clinician doesn’t have the answer themselves. This is when consultative services come into play. Whether I’m looking to a radiologist for a read on a CT scan, or asking a stroke neurologist for their help in deciding to treat a stroke patient with TPA, If one clinician is asking another clinician to collaborate and share their expertise, that’s a consultation.

The same way that EMR’s are the right tool for clinicians and PHR’s are the right tool for patients, TeleMedicine lets clinicians connect with other clinicians to remove the geographic barriers to consultations, TeleHealth connects patients to clinicians, and makes it possible to deliver care regardless of distance.

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Why telehealth is so scary… Thu, 28 Apr 2011 22:24:16 +0000 more »]]> I’ve been hearing quite a bit lately about how telemedicine (connecting providers to other providers for virtual consultations) and telehealth (connecting patients to providers for virtual care) are exciting new technologies, but that there just isn’t enough return on investment (ROI) to justify the cost of implementing them. The truth is, there’s massive ROI potential from this kind of care model, but existing providers simply don’t have much motivation to pursue it.

Telehealth is scary to existing healthcare systems, because it fundamentally changes the paradigm of how healthcare is delivered. In order to provide modern healthcare, we’ve always had to create massive “care factories” (also known as hospitals). Existing healthcare players have become pretty good at operating these care factories under the existing system’s rules. They are pretty happy with that situation, also, because the ridiculously high costs associated with building and running these factories protect established players by creating incredibly high barriers to entry into the healthcare industry. It’s also meant that the hospitals have become a vortex, sucking providers, services and patients into their field of influence.

Telemedicine and telehealth remove geography as a barrier to care. That means that suddenly, it’s possible to push out healthcare to the patients, rather than centralizing providers and pulling patients to our giant, expensive care factories. That’s incredibly disruptive!The reason that most existing healthcare institutions don’t see an ROI on potential telehealth investments is that, like legacy players in other industries, they can’t manage to break free of the shackles of their existing business models and value networks. They’re mired in the sunk cost investments that they’ve made in their big, inefficient, care factories and the systems that support them.

The groups that will be successful are the nimble new companies that can leapfrog the need for traditional “bricks and mortar” care, the same way that developing nations have leapfrogged expensive, labor intensive, wired telecom and gone straight to cellular systems. Leveraging this kind of technology with innovative new, low-cost business models (think call centers and mid-level practitioners), and logical new networks of value that bypass the traditional fee-for-service system.

The value of telehealth isn’t the real issue. It’s the fear of disruptive innovation that’s the true obstacle.

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We do NOT need more PCP’s Sun, 24 Apr 2011 23:17:59 +0000 more »]]> The obvious fact is that despite the pending shortage of primary care providers (PCP’s)there’s no way to increase their numbers in a timely way. But that’s OK. Why? Because what we need isn’t more availability of PCP’s, it’s more availability of primary care services. That’s a subtle distinction, but an important one.

Another way to say this is that what we really need is not more providers, but a better way to meet healthcare consumer’s needs; and in order to do that well, the we’ve got to better understand what those needs are.

When a patient wants the healthcare system to manage a complex chronic disease like diabetes, their needs could probably be expressed as something like, “build a trusting relationship with me, know my medical history well, and create an effective long-term care plan”. Traditional primary care generally (well, maybe the better word is “hopefully”) does a pretty good job of meeting these kinds of needs.

Now imagine the same person who now wants the healthcare system to manage a itching, burning, uncomfortable (but clinically non-urgent) rash. Now their needs are different. What they want is more like, “Evaluate me ASAP, make sure I don’t have something more serious, get me the medication I need, and make it happen conveniently and cheaply”.

Our traditional primary care system is notoriously bad about meeting this second set of low acuity, high volume “On-Demand” consumer needs. The good news is that there are potential solutions that provide more availability of primary care services and better meet patient’s desires for on-demand care. These solutions are likely to involve using web-based technology to improve the efficiency of lower cost mid-level providers, like nurse practitioners (NP’s) and physician assistants (PA’s).

So let me digress for a minute and tell you a personal story about the last time my sister had a nasty cold. It had been hanging on for about 8 or 9 days. For the last two or three, she had been feeling worried that it might have progressed to something more serious. She felt anxious and lousy. When she finally decided to go see her PCP, she had to pack up the kids (who were also possibly not feeling particularly well) and get them into the car, drive them across the city to get to the doctor’s office, herd them into the clinic and manage them during the 20-30 minute wait in the lobby. Once she got called back to the exam room, she had to round up the kids and get them back into the treatment room, and entertain them for another 15 minutes before the provider saw her. Once the doc was in the room, my sister then had to try and settle the kids down for long enough to have a productive conversation with the provider, only to be told that she really did just have an uncomplicated viral URI, and that there is no prescription that would be particularly helpful (but the Tylenol and Robitussin DM she already had in our medicine cabinet back home would work just fine). At this point, still feeling sick, and now feeling both exhausted and frustrated, she herded the kids (who have become increasingly bored and unruly) back to the car, and dragged them and herself back home. All in all, from start to finish, it was a harrowing two-and-a-half hour ordeal. The sad thing is that this is actually considered a “good” experience, since she was able to get a same-day appointment with her PCP!

Not only was this a terrible patient experience, it’s also a strikingly inefficient workflow for the provider. In these kinds of situations, the diagnosis is more than 95% dependent on history taking. Assuming that the history is consistent with an uncomplicated viral URI, there are no physical exam findings that will change my diagnosis and treatment plan. I spend 10-15 minutes trying (between child-induced interruptions) to ask the patient a series of routine clinical questions, and then document my findings in the medical record. It’s not a particularly challenging or rewarding professional experience, since the questions and diagnosis are very algorithmic. The one up-side is that I can bill roughly the same for this visit as I did for the poorly managed diabetic with refractory hypertension and dyslipidemia (We can talk more about THAT problem in a future posting…)

Now lets wave our magic healthcare wand and create a more ideal situation. Instead of suppressing her growing anxiety for two to three days because of her dread around the terrible issues of a traditional PCP visit, she goes to a website and from the comfort of the couch at home, she answers the exact same routine clinical questions. Using some pretty basic programming, the web tool arrives at the exact same diagnosis and treatment recommendations as I would have in the clinic. The questions, patient responses, and clinical recommendations are passed to a licensed mid-level provider (perhaps on their smart phone) who can review and approve them (or make modified recommendations) in less than 5 minutes. When the provider submits their approval, the entire encounter is automatically charted in its entirety with far greater speed, consistency and accuracy than would be possible in a traditional clinical encounter, and the whole transaction takes less than 30 minutes.

Doing just the math, we’ve improved provider efficiency by more than 75% (5 minutes vs 20), and shifted care from an expensive physician ($195,000 per year) to a less expensive but equally capable nurse practitioner ($110,000 per year). Now multiply that out times the 30-50% of patient visits that could be managed with this kind of care model. That’s huge healthcare savings. On top of that direct savings, the system has also created value by allowing providers to practice closer to the top of their license. In other words, we’ve freed up the physician’s time to manage more complex patients that their additional training makes them more qualified to manage. Just to put icing on the cake, let’s not forget that we’ve also reducing the patient time cost by 80% (30 minutes vs 2 and a half hours), and improved the patient experience, well, nearly infinitely.

That’s a pretty clear path to improved healthcare value.

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