Category Archives: Leadership

Day 65: Proof is in the Passion – Crossover Explained

Passion

Tonight I attended an awesome charity event called Savannah’s Organic Ranch. Savannah was a beautiful girl stricken with cancer whose last wish was to pass along her love of organic farming. The spark that was her life and encapsulated in her last wish has fueled a community wide passion for spreading representative organic “ranches” at local schools and in our community. I was impressed with the passion of this young girl, and how it has inspired equally vibrant passion for those who wish to keep her memory alive for a great cause.

I believe passion is an integral part of life and anyone’s life’s work. At several forks in my professional journey, I have chosen to pursue my passion instead of settling for a more secure road. It has been a defining characteristic in my life – one in which I have occasionally questioned during challenging times but have always known was my destiny. I find myself once again passionate about what I am attempting to do, and the familiar sense of being energized by both the general impossibility of the task at hand coupled with the equally strong sense of inevitability with which all entrepreneurs are endowed.

Instead of writing it out, I thought I would just capture what I am doing on video:

Saves me time, provides some strong visualization of our business, and hopefully conveys the passion I feel about what we are doing.  We will be using this blog and our other channels to tell our evolving story, as well as the entrepreneurial extremes we experience as we drive toward launch. Hope to make this a dialogue as we roll forward.

* For those of you wondering whats up with our broken down building, this video was shot by Benny Ek Media within our new space following its demolition. We look forward to introducing our new design, look and feel.

3 Comments

Filed under Consumerism, Crossover, Direct Practice, Leadership, Uncategorized, Value

The next 15%: The Software Enabled Services Concept

Software Enabled Services

  1. Professional service offerings that leverage software to synergistically deliver higher levels of performance than obtainable from either alone.
  2. A next generation construct which builds upon the concept of Software as a Service (SaaS) but involves the actual human delivery of the services.

I am here in Las Vegas at the athenahealth user conference. Jonathan Bush is on the MIC regaling the crowd with his usual unique style of charismatic evangelism (“um…this is a pie chart, lots of lines, lots of things, yada yada yada”). The crowd is a typical demographic of office management set as seen across America – a middle aged office staff crew, mostly women, and mostly worried about the day to day activities of running a practice. They are here, I assume, because they want to learn how to leverage a very powerful practice management and electronic health record software. However, I wonder how many of them understand that what they really have is the most powerful software enabled service (SeS) offering in the industry.

We implemented athenaHealth (both Collector and Clinicals) in December 2009 at a traditional medical practice that Crossover Health manages.  We noted an immediate 5% bump in our revenue through better documentation, we accelerated our collections 5%, and because of new capabilities we were able to modify our staffing which reduced our costs by another 5%. This 15% uptick in revenue is real, noticeable, and has had an immediate impact on our practice.

All these advantages could be had by implementing probably most any reasonable EHR/PM software system. However, the reason I am attending the conference isn’t for this first 15% efficiency gain, its the next 15%. This next 15% is much harder and where I believe our partnership with athena will pay big dividends.  I am attending the conference not to optimize “points and clicks”, but rather to better understand the “nodes and grids”. I am here to learn how to plug in and play up the network effect and power grid that is athenahealth.

Think about it. Our little practice is one outpost in a networked grid of practices “fighting the man” every day. We are all working off the same software, sharing our collective knowledge we gain every day, wearing down the inefficiencies of each practice, measuring and monitoring our improvements, and taking advantage of nearly 2,000 athenistas who work around the clock to ensure that my practice gets Paid More, Paid Faster and with Less Work every single day. I get a monthly Practice Performance Report which compares my little clinic to the best benchmarking in the network, that clearly delineates areas of improvement, and provides a support infrastructure to help me get there. The financial controls on my practice are unprecedented; and only made possible through the network effect of my colleague clinics and the centralized efficiencies inherent in athena’s business model.

The software enabled service approach is well on its way to closing the second 15% gap, and best positioned to initiate the hunt for the third 15%  – the uncharted and untapped area of clinical process and outcome improvement. I can’t wait to see athena apply their patented approach to the measurement, monitoring, and continual improvement of the clinical side of medicine. This will only happen as financial incentives become aligned with excellent clinical outcomes, and no one is in a better position to do that than athenahealth.

1 Comment

Filed under Conferences, Innovation, Leadership

#FAIL! Proprietary EHR Lock In through CCHIT

Lame (lām) adj.

  1. Disabled so that movement, especially walking, is difficult or impossible:
  2. Weak and ineffectual; unsatisfactory:

I just saw some seriously lame legislation proposed out of New Jersey by some ill-informed congressional lackey MANDATING that all EHR’s be certified through CCHIT. This is absolutely ridiculous. Do you really want to outlaw Google Health and Microsoft HealthVault in the Garden State? I mean get real!

The unintended consequences of such legislation is highly problematic and well described by David Kibbe, Fred Trotter, Ignacious Valdez, Neil Versel, and others. I have seen CCHIT make great efforts to correct this and make the process more open but they have a fundamentally flawed and constrictive position – that they alone can bestow the quality seal of approval on software.

They don’t realize, of course, that any attempt to subvert innovation will be futile. “Life always finds a way” (or in this case innovation). The notion of a new type of communication platform that will emerge as a result is already underway. Designated “Clinical Groupware” by David Kibbe and others or a new “Communication” platform by Myca or American Well, new tools will continue to emerge that defy current descriptions. Are you sure you want to lock down into today’s technologies through an already arcane certification process?

I would strongly argue that standardizing features and functionality is not the problem. These should be allowed to freely evolve and grow per the needs of users and the skills of developers. What should be standardized is the interoperability requirements of data, the database requirements, and related infrastructure elements that will enable the data to be truly liberated. These standards will do more for the industry than any other single legislative or policy initiative. This is where we need government help to force agreement on specific principles where the choice is not as consequential as just making a decision (driving on left or right side of the road is irrelevant; but it is clear that we need to make the determination!).

Legislative mandates for features and functions = #FAIL!

3 Comments

Filed under EHR, Industry, Leadership

Transcript to Transformation: Twitterview with @Berci

Twitterview (twĭt’ər vyū) n.

  1. A twitterview is a combination of the terms Twitter and interview.
  2. The Twitter medium of 140 characters forces a concise style of interviewing and response.
  3. The public can join in on the conversation and become participants themselves by following along or tracking hashtags.

On March 26, 2009 the leading health care bloggers (see list below) throughout the blogosphere participate din a Blog Rally to raise awareness for public participation in the Healthcare X PRIZE design. Bertlan Mesko, leading Medicine 2.0 Advocate and author of the popular Science Roll blog, also conducted a “Twitterview” in support of the effort.

Berci: Can we start the twitterview now? I’d have 10 short questions, you may have 10 short answers. So everyone can enjoy it.

HealthXPRIZE: Thanks for taking the time. We appreciate your help in getting the word out. This Twitterview will complement the Blog Rally. Ready!

Berci: Great! First, what is the X PRIZE Foundation? What is the X PRIZE model?

HealthXPRIZE: The X PRIZE Foundation is a non profit organization that conceives and operates large incentivized prizes that lead to revolutionary breakthroughs. The X PRIZE model is based on leveraging a large purse, with a clear set of rules, that allows innovators to break through barriers.

Berci: Please tell us more about Healthcare X PRIZE!

HealthXPRIZE: The Healthcare X PRIZE is intended to be a competition to redefine health and demonstrate how new models of care can dramatically increase health value. We chose to focus on health value as opposed to a new wonder drug or device as our sponsor (WellPoint and WellPoint Foundation) & advisors were most interested in a systems prize. Systems prizes are much more difficult to conceive and operationalize than technical competitions like going to space or even replicating the genome rapidly. We are expecting that teams will need to innovate around health finance, care delivery, and individual incentives to increase health value. We are currently developing a clear set of rules, which provide the parameters of competition, as we believe that “creativity loves constraints”.

Berci: Reforming the US healthcare system is quite a brave mission, isn’t it? Why the focus on health value?

HealthXPRIZE: The US Health reform gets serious this summer and the HXP is well timed to actually demonstrate and prove in practice the principles of reform. Value is powerful organizing principle for reform efforts – we cannot just reduce costs, nor can we just attempt to improve quality without financial accountability. The focus on health value highlights the need to focus on both sides of the equation. Since Value =outcomes/cost, we are challenging teams to improve both simultaneously.

Berci: Why use an incentivized competition?

HealthXPRIZE: Incentivized competitions are very efficient, highly leveraged, and create an “X” factor within the competitive framework. Sponsors only pay the winner, a $10MM purse typical spurs >$100MM of investment, and the X factor creates global media attention to a key problem, inspire hero’s, encourage non-traditional thinking, and creates a powerful incentive for innovation.

Berci: And how can you properly measure health value? I guess you need pre-defined parameters. What are these?

HealthXPRIZE: Health Value has never really been measured within the US Health Care system. There are many efforts underway right now to properly define and measure health value. Many innovators are leading the way and we are attempt to build on their work or actively collaborate with new/ongoing initiatives (Dartmouth, IHI, AHRQ, etc) to solidify the health value measurement framework. In the context of competition, we are trying to make our measurement framework as concrete as possible by focusing on outcomes (mortality, specific morbidity, ED visits, hospitalizations, sick days etc.). Effectively communicating the notion of “health value” remains a challenge; we are considering focusing on aspects of health value (like decreased hospitalizations and sick days) as a more effective way to communicate to the public the hoped for prize breakthroughs.

Berci: How are the Teams and Test Communities Selected?

HealthXPRIZE: Teams will be selected by through a series of concept design and testing evaluations. They will be required to demonstrate or model the impact of their proposed interventions against test database provided by WellPoint. Independent judges will evaluate the merit/validity of the concept in order to advance. Communities will be selected based on specific criteria that are still being worked through. Intent is to have a defined population of 10K participants from which Teams will voluntarily enroll in the intervention. Test community will be matched against a geographically adjacent control group. Both the team and community selection requires further design, detailed analysis, and expert opinion which we are soliciting at this time through our network of national measurement experts.

Berci: When does this competition start and when will it end?

HealthXPRIZE: The “competition” has several phases: Design, Selection, Competition. We are currently in Design phase through our anticipated Launch later this fall. The Design phase includes soliciting public comment on how we can improve our initial concept/construct to create the most viable competition possible. After official “Launch”, we will begin recruiting teams to compete. Teams will then be narrowed as described above through late Spring 2011 when 5 finalist selected. After a brief integration period into test community, HXP competition is planned to officially begin in January 2012.

Berci: How does this shift the paradigm? What kind of outcome do you expect?

HealthXPRIZE: Great question – we believe the current paradigm is based on volume not value, on process not results, and incents the wrong behaviors while delivering bad outcomes. We want to shift the paradigm to rewarding the reduction of hospitalization / sick days and begin to pay for overall health improvement (this is the outcome we want!). We also want to not focus solely on disease care, and aren’t interested in just improving health care; but believe that we must move to an entirely new notion of engaged, activated health called “Vitality”. We want to demonstrate that this CAN be done at scale, with new entrants / new ideas, and want to set the HXP up as a framework from which these efforts can be tackled in the real world. By focusing on outcomes, instead of regimenting care processes or dictating care delivery, let providers/patients innovate and create rewards for those who obtain the best outcomes.

We believe incentivized competitions are a great vehicle from which we can accelerate change, shift the paradigm, and be a catalyst for the transformation that is required for the US healthcare system. We hope the outcome is a new way to think about health, measure health value, and demonstration of new models of care that demonstrate how to improve community health and individual vitality.

Berci: My last question, regarding X-PRIZE – first rockets, then genomics, now healthcare. What do you think? What’s next?

HealthXPRIZE: XPRIZE is a mission driven organization seeking to inspire the very best in human kind for the benefit of all – this isn’t just a nice quote. It is inherent in the DNA of the organization. We are attempting to be the catalyst in any “stuck” industry by creating incentivized competitions that can lead to radical breakthroughs to the grand challenges of humanity. HXP is now looking at education, energy (some really cool stuff), and developing world initiatives that can truly have major impacts. Fortunately for me, HXP is our focus for launch this year. It is quite challenging work, deals with multiple hard to think through issues, but includes the privilege to work with great people and teams including our sponsor WellPoint.

I have been thrilled with the level of commitment to this process and this prize development process has been tremendous experience. They have a very talented innovation team, led by Chad Pomeroy, who is fully supported by senior executives all the way up to Chief Executive Officer Angela Braly. They have been driving this initiative forward far beyond the $10MM prize purse; they are providing operational resources, sharing data, working to create appropriate test communities, altering business practices to accommodate the prize, and are committed to transparency as part of the HXP process. Their commitment to the project is the reason I became involved as I saw an unprecedented opportunity to really implement the innovation in an idealized but competitive test environment. We appreciate WellPoints leadership, foresight,and commitment to engage X PRIZE in developing the Healthcare X Prize for benefit of all. Very cool stuff.

Berci: Thank you very much for the interesting answers! I will publish the transcript on Scienceroll.com in a few minutes.

HealthXPRIZE: Berci, again, thank you for this twitterivew. We hope to have everyone visit our website, download the initial prize design, comment on our blog, and add their input to the Prize Design process.

3 Comments

Filed under Health Finance, Healthcare, Industry, Innovation, Leadership, Quality, Rational Choice, Transparency, Uncategorized

The Geisinger Experience: Realizing The Health Value Vision

Realization (ə-lĭ-zā’shən)

  1. The act of realizing or the condition of being realized.
  2. The result of realizing.

Today, I am meeting with the X PRIZE Foundation at our 2nd Health Advisor Summit meeting in Washington, DC. We have gathered a small subset of health care thought leaders, innovators, providers, payors, patients, and employer groups to discuss the design of an incentivized competition for our health care system. It has been and continues to be fascinating work.

I have been privileged to talk to some of the luminaries within the health care field, individuals that I have read about for years (Weinstein, Nussbaum, Schwartz, Pardes, etc), but now have the privilege to interact with on a near daily basis.  One of those, Dr. Glenn Steele from Geisinger Health, has been particularly enjoyable to work with. I have been impressed with the incredible work they have done at Geisinger, not just their outcomes, but their thought process and the leadership behind making the required changes to achieve the results they have.   Glenn has actively participated in the X PRIZE design, and I have been impressed with his insight, his approach to problem solving, and what his team has accomplished to date.

They are the rubber hitting the road for the value driven health movement. Dr. Steele recently presented to Congress, and the entire body of his comments are included below because they are that good . . . and provide some insight into some of the transformative new deliver and new payment models that the X PRIZE hopes to catalyze. It is a bit long, but well worth your time (highlights are mine). For those who need to go right to the punchline, here it is:

The money quote: “We have improved outcomes and have reduced costs. This is because we have systematically researched how best to deliver care, hardwired the process steps into our electronic health record to prompt us on what best practices are, decreased unjustified variation, and taken financial risk to decrease related complications.”

Healthcare Reform – Changing Reimbursement That Reflects Value

April 1, 2009

Chairman Rangel, Ranking Member Camp, and members of the Committee,

Thank you for the invitation to testify at your hearing on healthcare reform and national system changes that can support quality and value in healthcare delivery. At Geisinger Health System, we serve a population that is poorer, older and sicker than the national averages. Most of our patients have multiple chronic diseases, such as diabetes, high blood pressure and lung disease. Our patients have difficulty navigating through a complex healthcare system. They need help and we have made a concerted effort to put into place electronic and other innovative methods that will provide them with the assistance to maximize their ability to get care.

At Geisinger, we hold ourselves to high standards of assuring quality outcomes in serving these patients. For example, if a patient is readmitted to a hospital after a procedure or an in-patient stay, we believe we have failed that patient. Consequently, we have committed significant resources and have worked aggressively to bring value to healthcare and eliminate failures by redesigning how we provide care. The innovations we have instituted at Geisinger that bundle payments for acute care procedures, enhance support for primary care physicians and their care teams, better manage chronic disease and the transitions of care for patients from caregiver to caregiver, have produced significant cost savings and improved quality. Admissions for our patients with multiple chronic diseases have been reduced by as much as 50% in community sites. I believe that what we have accomplished can be adopted nationally and will achieve similar cost savings while improving quality. This would result in significant positive consequences for large payors, particularly Medicare.

Background

I am Glenn Steele, the President of the Geisinger Health System, an integrated healthcare organization located in central and northeast Pennsylvania. Before coming to Geisinger, I spent 20 years as a practicing cancer surgeon at several Harvard hospitals and served as a Chairman of the Department of Surgery at the New England Deaconess Hospital. I then became Vice President for Medical Affairs and Dean of the Division of Biological Sciences and the Pritzker School of Medicine at the University of Chicago. Consequently, I have firsthand experience with patients, their access (or lack of) to care, issues that affect physicians and other caregivers in providing adequate and timely care, and the difficulties in juggling medical education and research, while facing ongoing changes in healthcare reimbursement.

In 2001, I came to central Pennsylvania because Geisinger offered the potential as an integrated healthcare system of developing cutting-edge approaches to increasing efficiency, value, and quality in healthcare. In short, we could attempt to transform healthcare using both our healthcare insurance product, and our clinical delivery system working together to benefit our patients. We serve a population of 2.6 million located in central and northeastern Pennsylvania. And we have an electronic health record (EHR) that was implemented 14 years ago with now more than 3 million individual patient records. Geisinger has been named as “Most Wired” by Healthcare’s Most Wired magazine six times.

We have our own health care insurance product – Geisinger Health Plan – that has nearly 235,000 members, 35,000 Medicare beneficiaries, 18,000 empanelled physicians, 90 hospitals (not including our Geisinger hospitals) and spans 43 of Pennsylvania’s 67 counties. We also lead our area’s regional electronic health information sharing platform1, called the Keystone Health Information Exchange, with (currently) ten hospitals and approximately 700 private practices sharing valuable medical information. This secure, patient-approved sharing of information means that our doctors, and more than 1,500 non-Geisinger caregivers can access patient information 24/7 from anywhere – a remote two-doctor primary care office, a multispecialty clinic, an operating room, or at 3:00 am from home.

Our patients access their own electronic health record. They can see their lab results, radiology results, request prescription refills, and email their doctors, nurses, and staff with questions anytime. And, they schedule their own appointments on-line. Geisinger has a large number of elderly patients (many greater than 80 or 90 and more and more now exceeding 100 years of age). Most have multiple chronic diseases and have family living outside of our area who follow their parents’ care through the electronic record (with appropriate patient approval). Geisinger employs about 800 physicians who see patients in more than 50 clinical practice sites; 38 of which are primary care sites in local communities. As clinically appropriate, physicians in these clinical sites admit their patients to nearly 20 local community hospitals – ensuring that patients receive most of their care near where they live. Only if necessary, are Geisinger patients treated at one of our three specialty hospitals.

Geisinger’s innovation2  is intended to attack fundamental flaws in our country’s payment for and delivery of healthcare. The U.S. suffers from a variety of reimbursement and care delivery issues that do not produce good clinical outcome. There is wide and unjustified variation in care. Fragmentation of care is rampant; our “hand-offs’ (that is, transferring important medical and family information as patients are moved from one environment to another) are disjointed and most often result in patient care that is not coordinated and is confusing to the patient. We have a perverse method of payment – one that rewards units of work regardless of patient outcome.

At Geisinger, we invest in quality and pay accordingly. Doctors who have better clinical outcomes are rewarded (financially and by recognition) and we constantly measure our outcomes against our peers, both within Geisinger and nationally. Physician, staff and site incentives are built into our system. And we reward quality and value, not just numbers of patients seen or numbers of procedures performed.

GEISINGER’S ACUTE EPISODIC CARE PROGRAM (THE “WARRANTY”) 1, 2 ProvenCare®

A great paradox in U.S. healthcare is that we get paid for making more mistakes. For example (with few exceptions), if a patient develops a post-operative complication that might have been avoided by proper care, we often receive more reimbursement for that case than for a comparable case without a complication. This does not happen in other industries. Why are healthcare services an exception? Consequently we believe our care design should be based on best evidence. In 2006, we started tackling the perverse payment incentives noted above by redesigning how we provide elective cardiac surgical care – what is known as coronary artery bypass grafts (or CABG)3. CABG is an episodic acute event – an event with a determined time frame from diagnosis through rehabilitation and recovery (unlike chronic disease, which stays with you for life). Our cardiology service line reviewed the American Heart Association and the American College of Cardiology guidelines for cardiac surgery and translated these into 40 verifiable best practice steps that we could implement with each patient undergoing this surgery. We hardwired these into our electronic health record so that we would be prompted to meet each identified step – or document the specific reason for any exception. We then established a package price that included costs of the first physician visit when surgery was deemed necessary, all hospital costs for the surgery, and related care for 90-days after surgery, including cardiac rehabilitation.

We named this program “ProvenCare”, since it is based on evidence or consensus of best practices by our heart experts. Pre-operative, post-operative and rehabilitation are part of the single charge. And we take the financial responsibility for any associated complications and their treatment. While our cardiac surgery outcome was already well above the national average, (and near the top of Pennsylvania’s PHC4 data set) upon initiation of this program only 59% of patients received all 40 best practice steps. Three months into the study, 86% were receiving best care. We raised that to 100% and, with few exceptions, have kept it at that high rate. As a result of implementing this “warranty” program, our patient care was better – using comparative, standardized data from the Society of Thoracic Surgery. We had a reduction in all complications of 21%, sternal infections were down 25%, and re-admissions fell by 44%. Costs for treatment fell, too. Our average length of hospital stay decreased by half a day4.

For other high volume, hospital-based treatments, we have now considered every step in the patient’s care flow. For instance, in orthopedic surgery, why should one doctor use one set of surgical instruments and prosthetic devices and another insist on a different instrument set-up for the same procedure? That type of variation often has no medical justification, results in unnecessary costs that are passed off to third party payors (such as Medicare) and, we believe, compromises patient outcome. We have expanded our experience with heart surgery to “warranty” programs that include:

  • hip replacement
  • cataract surgery
  • obesity surgery
  • prenatal care for babies and mothers (supported by the March of Dimes) – from an infant’s conception to birth
  • centrally- managed, evidence-based use of high cost biologicals, such as EPO (erythropoietin)
  • heart catheterization

We have improved outcomes and have reduced costs. This is because we have systematically researched how best to deliver care, hardwired the process steps into our electronic health record to prompt us on what best practices are, decreased unjustified variation, and taken financial risk to decrease related complications.

ProvenCare – Chronic Disease

In reforming how we deliver care at Geisinger, it isn’t enough to simply address acute episodic care. The major challenge of healthcare in the U.S. is now chronic disease treatment and “secondary prevention”. We identified the most common chronic diseases – diabetes, coronary artery disease, congestive heart failure, kidney disease – and have applied evidence or consensus-based best practice thought to limit disease progression. Called “bundled” care, we have designed each of these steps into our care pathways and strive to achieve as close to 100% adoption as medically appropriate and feasible. In the case of diabetes, we began to track how we performed in meeting 100% of the expected “bundle” of best care for diabetic patients three years ago. Our primary caregivers have chosen to receive compensation based on how many of their 25,000 diabetic patients reach optimal levels in the practice “bundle”, not solely on how many patients are seen each day or how many tests are ordered.

ProvenHealth Navigator (Advanced Medical Home) 3, 4

Geisinger’s patient-centered medical home initiative (called ProvenHealth Navigator) combines traditional medical home models with patient engagement and is designed to deliver value by improving patient care coordination throughout the system. Our Advanced Medical Home currently covers 30,000 Medicare recipients and 3,000 commercial patients, with plans to expand this base. We understand that navigating through the complexities of any healthcare system is not easy, so we have invested in programs and staff to help support each patient’s journey, placing dedicated nurses in each targeted outpatient clinic. Over 200 Geisinger primary care physicians diagnose and treat their patients locally in 38 community practice sites. Our “embedded” nurses are paid for by the Health Plan, becoming critical members of the community practice team and, with the physicians, are expected to know the patients and their families, to follow all of their care, help them get access to specialists and social services as necessary, follow them when they are admitted to a hospital, contact or see them when they are sent home to confirm that they are taking the appropriate medication dosages, and be available for advice 24 hours a day.

Importantly, we don’t just ask these community-based clinicians to “try harder” or “work faster”; we use resources from our health plan to help redesign their work. And, we pay incentives for getting the job done. In our best practices, our sickest chronic disease patients’ admissions were decreased by 25%, days in the hospital decreased by 23%, and readmissions following discharge decreased by 53%. The payback for the health plan occurred within the first year. The benefit to patients and their families avoiding multiple hospital admissions was priceless! For these patients with multiple chronic diseases, transport to and from the hospital or clinic, choosing which doctor should be seen, coordinating their numerous prescriptions, getting their pills, making sure they take their pills at the right time – all of this is what our ProvenHealth Navigator work redesign accomplishes. Increased quality for the patient and their families actually lowers healthcare costs.

Summary

Building on what we have done at Geisinger, I have these recommendations for your consideration:

  • Establish a simple, understandable set of national goals, so we can hold ourselves accountable together for improving the quality and value of health and healthcare for our citizens.
  • Change reimbursement to reward positive outcomes, not units of work.
  • Pay for episodes of care, forcing all providers to work together across physician and hospital boundaries to achieve optimal outcomes.
  • Pay more for delivering high value primary care.
  • Fund innovation to create real or virtual integrated systems of care.
  • Consider capitation payments linked to quality outcome measures for prevention and chronic care services.
  • Help fund enabling information technology but insist on non-proprietary interoperability.
  • Do not pay for mistakes and do not pay for care that is of no known benefit.
  • Help hospitals and communities establish transitions of care programs to reduce unnecessary admissions and readmissions.

Thank you again for the opportunity to testify today and I look forward to your questions.

References

  1. Walker J, Carayon P, From Tasks to Processes: The Case for Changing Health Information Technology to Improve Healthcare. Health Affairs, Vol. 28, No. 2, 467-477, 2009.
  2. Paulus R, Davis K, Steele G, Continuous Innovation in Health Care: Implications of the Geisinger Experience. Health Affairs, Sept/Oct 2008. Vol. 27, No.3
  3. Casale A, Paulus R, Steele G, et al ProvenCareSM. A Provider-Driven Pay-for-Performance Program for Acute Episodic Cardiac Surgical Care, Annals of Surgery. Vol. 246, Number 4, Oct. 2007
  4. Abelson R. In Bid for Better Care, Surgery With a Warranty. The New York Times. May 17, 2007.

3 Comments

Filed under Episode of Care, Health 2.0, Healthcare, Innovation, Leadership, Medical Home, Quality, Uncategorized, Value, X PRIZE

Primary Care Possibilities – Kaiser Leads the Way (again)

Leadership (lē’dər-shĭp’) n.

  1. The position or office of a leader
  2. Capacity or ability to lead
  3. Guidance; direction

I have written extensively about Kaiser Permanente in the recent past (here, here, and here) – not only for their notable achievements but even more impressive to me is their genuine interest to share their results with others as model for global health improvement. The recent issue of Health Affairs has two impressive articles from Kaiser regarding their EHR implementation as well as their Online Portal efforts. Great material.

As part of the same issue, Health Affairs newest contibutor Carleen Hawn highlighted the work of Ted Eytan in an article discussing the new social media delivery model. The article was a campy, highly conversational piece introducing some Millennial Vibe into what has always been the hushed tones of the highly academic/policy focused Health Affairs. Ted continues to do alot of interesting work, and in his role at Kaiser travels the country looking at new models of care delivery, new technologies, and the beautiful symphony that occurs when patients/physicians are working together in partnership to optimize health. A recent blog post of his highlights some of what he is seeing within Kaiser in terms of delivering more valuable primary care to patients. I thought it was worthy of re-posting large sections:

Because the innovation in primary care they are helping create involves all members of the care team, they created an experience for me that included shadowing physicians as well as nurses and clinical pharmacists. We should understand how every member of the team contributes, and this was great.

So what did I see?

  • Data systems and the workflow to support it are maturing to the point that primary care teams can understand how to keep patients healthy whether or not they actually come in for appointments. Teams are alerted about patients with chronic illness proactively, not reactively, more quickly than ever before. Medical and Nursing staff are responding to this new ability by creating new workflows and partnership around supporting patients, families, and populations.
  • Physicians are comfortable with the comprehensive electronic health record in practice: quote from an Ohio Permanente physician, “I don’t want the computer to get in the way (of the visit) but at the same time it’s a wonderful opportunity to share with the patient.”
  • Participation of a wider array of team members including nurses and clinical pharmacists, to leverage their skills, whether it’s coaching/teaching, medication management, all connected electronically (now).
  • Rethinking of the primary care practice altogether – including the idea that primary care physicians may see higher acuity patients as population management is spread across more staff, that they will use non-traditional communication methods including secure e-mail and telephone as part of what they do, and that managing a panel is work integrated into the day.
  • My favorite After Visit Summary workflow – every member whose care I observed got one – physicians and nurses work together to create and go over information with patients, it is not just a task of one or the other. They use the electronic health record to signal each other consistently for the handoff, which happens reliably. This helps accuracy and efficiency for the member and the system.

I think this work is not only useful for Kaiser Permanente, but for all of health care, because Kaiser Permanente’s financing model allows for this type of innovation, and sharing of such.

At the same time, there are major challenges here. The primary care provider shortage has affected Kaiser Permanente as much as the rest of health care. The good news is that this shortage is driving many of the innovations above, which I actually think will be portable to all of health care.

Wow. High performing health systems do more with less, do less for each patient (because the patients do more themselves), and involve a team approach given their aligned incentives all focused around a patient centered experience. I also love that they are willing and wanting to share their experience, to help others see the possibilities, and working together to improve our health as a nation. Isn’t that the essence of leadership?

Bravo, KP!

2 Comments

Filed under Change Agents, Innovation, Leadership, Medical Home, Quality

“Systemness”: Which Delivery Model is Best?

Systemness (sĭs’tə-m nes) adj.

  1. Arrange according to a system or reduce to a system
  2. The degree to which something shares the attributes of a system

Last week I attended the World Health Care Congress Consumer Connectivity conference in San Diego. The Twitter stream was at near flood capacity, and several excellent speakers were present to share their ideas. Conference attendance was affected by the economic climate but I believe the course of dialogue, the information shared, and value of the networking still proved worthwhile.

I shared a panel with Jordan Shlain, MD the founder and Medical Director of Current Health. I served as an advisor to the company through the late summer / fall and participated in their launch in December at World Health Information Technology Conference in Washington DC. Our presentation was intended to focus on “Millennial Technologies for the Medical Home” but given the light attendance, we essentially abandoned our traditional presentation given the intimate setting. After a brief introduction from me regarding the notion of Millennial Patients demanding Millennial Care, Dr. Shlain spent the balance of the session sharing some of the reasoning, thought, and opportunity behind the “direct practice” concept of Current Health.

During the presentation, several examples of “fortress medicine” were shared, including some which highlighted some individual failures and market perceptions with Kaiser and other large providers. The conversation took a couple of pointed turns as several Kaiser employees were in attendance (including an excellent Twitter follow in @janoldenburg). As Dr. Shlain would highlight individual cases which created opportunity for Current, they were countered by persuasive examples and initiatives from the Kaiser team. Abstracting out the tone, the content of the conversation was instructive in terms of alternative models of care.

Integrated health delivery systems deliver better results, period. The evidence is overwhelming as identified by the Dartmouth Atlas and countless other studies. We need to move our country to more “systemness”, which implies coordination, teamwork, shared learning, shared responsibility, and a long term perspective with aligned financial incentives. This is why I love the vision and the promise of true “health systems” like Kaiser, Intermountain Health Care, Group Health, Geisinger, and others.

However, Kaiser and all of these systems, are not perfect (nor claim to be) and despite systemic results that are superior there are individual failings (which seem to find their way into the sensational or anectdotal) that creat opportunities for viable delivery method alternatives. The notion of the medical home, or its complementary concept of Concierge Medicine, is also a “system” of care wherein a single physicians assumes the role of integration and patient experience. Assuming accountability to deliver this “virtualization layer“ enables these physicians to approximate the degree of integration that leads to better outcomes. These organizational delivery concepts have been created to remove the clinical and financial friction and frustration inherent in our current system and deliver personalized care that is safe, effective, patient-centered, timely, efficient, and equitable. We are also starting to see the positive results from these early studies.

The bottom line, we can no longer tolerate our uncoordinated, fragmented, silo’d delivery mechanisms. We must create “systemness” through all the appropriate means as any production organization has had to do as well. The culture of quality and outcomes must be built into the health care processes themselves and their must be rigorous, ongoing improvements with shared learning as the results are captured. This systemness, by any means necessary, will be good for our nations health.

2 Comments

Filed under Current Health, Direct Practice, Health 2.0, Innovation, Leadership, Medical Home, Value