Finding Fixes Locally

At home for some Easter celebrating, getting caught up on local news.

The realities of our fractured system require constant innovation, workarounds if you will, to deliver care to all.

In Charles Leadbeater’s TED presentation I posted earlier, he speaks of the difficulties of innovation in larger organizations. Smaller organizations’ ability to innovate is often necessary for survival.

To combat the problems associated with uninsured patients and their potential eligibility for financial assistance, a trio of organizations have come together to make this scenario (a 23 page application!) easier for patients:

A joint effort from ACMC, Avera Marshall and Lincoln, Lyon and Murray Human Services has resulted in a financial assistance office inside Avera Marshall and right next to the ACMC clinic attached to the medical center. The office will help patients and their families complete the applications to determine eligibility for assistance.

I am especially fond of the localized solution and the ability for citizens, government, and non-governmental entities to work together to find a fix. Best quote: “The cooperation between a governmental agency, a non-profit hospital and private clinic may be the only such model in the state.”

Medical Students, Residency Programs, and Incentives

The New York Times has an article today (in the Fashion and Style section no less) on the competition that medical students encounter for high-paying specialties—specifically dermatology and plastic surgery.

We all know the issue, but just in case:

“It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in Chestnut Hill, Mass., who chose his field because he wanted to perform procedures, like skin-cancer surgery and cosmetic treatments, while keeping regular hours and earning a rewarding salary.

Medical school professors and administrators say such discrepancies are dissuading some top students at American medical schools from entering fields, like family medicine, that manage the most prevalent serious illnesses. They are being replaced in part by graduates of foreign medical schools, some of whom return to their home countries to practice.

Although out of context, this quote is quite scary: “Last year, the school (Emory University) enlarged its incoming class, hoping more students would specialize in the major diseases and preventative care.”

With medical students leaving school with debt loads in the hundreds of thousands of dollars, “hoping” will do nothing.  Changing incentives (reimbursements, loan forgiveness, etc.) will.

The Patient that Co-Produces Health Care

The customer as a co-producer has been around for some time: deposits at the ATM, self checkout at Wal-Mart, cut down your own Christmas tree…

The self check-in at the airport model has arrived in hospital emergency departments, here in Dallas, here in New York, among others.

I have been reading about Charles Leadbeater and his new book “We Think.” Way back in 2005, Mr. Leadbeater spoke at TED, and thanks to TED’s willingness to share, we can watch what he said: talks about collaborative communities and their impact on innovation. Mr. Leadbetter especially caught my attention near the very end of his talk:

If you are a games company (online software), if you have got one million players in your game you only need one percent of them to be co-developers contributing ideas and you’ve got a development work force of 10,000 people. Imagine you could take all the children in education in Britain and one percent of them were co-developers of education, what would that do to the resources available to the education system? Or if you got one percent of the patients in the NHS to in some sense be co-producers of health?

The reason why despite all the efforts to cut it (collaborative co-production) down, to constrain it, to hold it back, why these open models will still start emerging with tremendous force is that they multiply our productive resources and one of the reason’s they do that is that they turn users into producers, consumers into designers.

The patient as a co-producer? This has some intriguing possibilities. And then I came across this…

e-patients brings us this story of a wrong-site surgery sentinel event in Minnesota and asks, “Defenders of the Walled City approach to medicine, please note: this was not caused by empowered patients Googling for medical information on unsafe web sites. To the contrary, can there be any doubt this could have been prevented if empowered patients and their families had been involved, with full access to their records, and had been reading them?”

Empowering patients to be co-producers of their own health is a great thing and one way to make our “system” more understandable. Much of the current web innovation in the health care arena is trying to do this. There are great possibilities for one percent of patients to become more involved co-producers of health care. But it is very important (for everyone that is able) to become a co-producer of their own health. Empowering the patient will make significant changes in our system…and it doesn’t require policy change or money.

Mr. Leadbeater also talks about how traditional organizations try to prevent innovation by collaborative communities. Traditional organizations typically provide incremental innovation where collaborative communities can provide giant steps in innovation. We’re seeing it already with sites that allow patients to rate doctors. There is debate on the fairness of such sites. But this is for sure: their proliferation is forcing action. That action is producing change.

Health Care’s Bully: Free

Free (paying nothing, receiving something) is definitely here. Well, it’s been “here” for a long time. It’s just acknowledged now. The web is built on free and its implications are widespread, blanketing every industry…and that includes health care. We have reached the point that any new business is seemingly building itself upon the Free model. As for health care and “old business,” the Free concept must not be ignored.

My discovery of Free insight transpired over the course of a few weeks and it started with Chris Anderson’s FREE! article in Wired, which is also the title of his upcoming book. Then I came across “Free Love” at Trend Watching. And then Free spread with many weighing in across the intraweb. PSFK has some highlights of Free. Blogspotting mentions our (humans) infatuation with Free and asks how to make a living on Free. As Seth Godin writes, the interaction completely changes when something is Free, “There is no commitment, one way or the other, for free.”

Health care analysis started with Health Populi and the free implications on health care information technology, especially web based Health 2.0 applications. This is a good place to start the Free health care discussion—it’s the first aspect of health care delivery to move digital—because as Chris Anderson says, “Every industry that becomes digital, eventually becomes free.”

The broader implications of Free health care are sure to send any old economy organization/service provider running. Look at some of the services that have gone digital, services that people once shelled out significant money for: university classes (download an entire MIT class or view lectures at UC Berkeley), scientific knowledge (a new(er) group of journals at PLoS allows the viewing of articles for free), communication (think of the email, instant messaging, or Skype calls one can do on free wireless networks), the list could go on for a quite a while.

Fred Fortin at the World Health Care Blog goes further in analysis, “The real and most interesting question has to do with the impact of free healthcare on those aspects of healthcare for which we pay dearly.” As we know, a provider’s response to payer reimbursement cuts is simple: increase volume. When actual health care services delivery is wholly affected by Free, volume increases will do nothing to supplement an entire decrease in reimbursement. It’s happening already, primary care physicians exchange email and phone calls with patients, in essence providing care, but unfortunately are not being paid for it. The real bad news for physicians, as is demonstrated by the music industry, is that once you start providing a service for Free, there is no way to return to the model of compensation, no matter the amount of litigation.

As we increasingly push health care digital (read: the web), how can we create value in a world dominated by Free? The important debate: not how can we prevent health care from becoming Free but how to add value in order to make money.

Kevin Kelly at The Technium offers, what else but, some free advice: It starts with examination from the user’s perspective, “why would we ever pay for anything that we could get for free?” Mr. Kelly goes on to describe eight generatives to combat free. “A generative value is a quality or attribute that must be generated, grown, cultivated, nurtured. A generative thing can not be copied, cloned, faked, replicated, counterfeited, or reproduced. It is generated uniquely, in place, over time.” Read about them here. Four generatives that I think will have the largest impact on health care: immediacy, personalization, interpretation, and findability. Feel free to comment on your thoughts.

But here’s the good news, the World Health Care Blog asks, “Healthcare is a late bloomer when it comes to the information technology revolution, but it will, as they say, suffer from 100 percent of the effects of that technology. Are we prepared and being mindful of the changes all around us? That remains to be seen.” As recently reported in The New York Times, late adopters are important in the technology adoption cycle.

The health care industry, being the late bloomer that it is (that’s putting it nicely), allows itself to learn from the trials and tribulations of the rest of the industrialized world. The feet dragging in health care gives us a window (although quickly closing it is) to research, test, and implement models that will work. Some have already started, don’t be left behind.

Contemplating the Future

Fred Fortin at The World Health Care Blog:

With the kinds of uncertainty we are now facing in US health care — 2008 elections, unsustainable costs and a growing politics of blame and greed — the future is less about, well, the “future” and more about the present, that is our ability to simply hang on for the ride. Both the pace and unpredictability of what now confronts us makes futurists look more like shamans trying to comfort a nervous patient, than professionals who can help us line up, in some understandable order, the drivers of change.

One thing is for sure, however, any official “futures”, at least for now, are DOA. And we don’t need to pay any futurist to tell us how that story will end since the the plot has still yet to be revealed. Stay tuned.

I completely agree. And I see us continuing to operate in this uncertainty for the foreseeable future.

Earlier in his post, Mr. Fortin says that we, in health care, are very concerned with the future. And I would agree when it comes to bed capacity, workforce needs, addition of programs, or what can easily be summed up as the “normal business” planning issues.

But when it comes to sustainability as an entire health care system, the theme receives little thought, if any, when future organizational decisions are being made. And why should it? All jobs in an organization are based on that specific organization’s sustainability.  It’s the Tragedy of the Commons.  While I believe some organizations are thinking about sustainability, that conversation doesn’t go beyond community or regional borders. So the role of creating a sustainable environment for the entire health care system falls to the government.

And there’s talk of making it happen, but it’s talk. And talk at the highest level breeds inaction at lower levels. Here’s an example: with the current rhetoric of health care reform by presidential candidates, and specifically both Democrats’ plans to cut costs through proliferation of health care IT, why would any hospital, physician’s practice, clinic, etc. even consider making their records electronic at this moment? The Democratic hopefuls both have plans to help organizations pay for it. So unless the investment explicitly helps an organization reduce costs (most likely only large organizations considering the substantial cost involved) in the relative short-term, why would anyone consider it when there is the potential for the government to help pay for it?

Here’s the problem: the wait could go on forever…and doing nothing continues the cycle we’re in.

Mr. Fortin’s post was inspired by a post by Kevin Kelly in which Mr. Kelly says the future doesn’t matter anymore:

The pace of change became so fast that it outpaced contemplation. The future became harder to predict, and exhausting to keep track of. With a long, colorful history of failed predictions, it occurred to almost everyone at once that very little of what we imagined our own futures to be would really happen. So why bother?

While we often contemplate the future of our organizations, the problem is just that—because the future that truly matters is that of the sustainability of our health care system.

Transparency is K-I-N-G: (Another) Redux

60 Minutes had an interview with Dennis and Kimberly Quaid Sunday evening, see video here.

The Quaid’s, if you will remember, went through a scary ordeal several months ago as their newborn twins were administered Heparin 1000 times that of which was prescribed. The gist of the story is that it was a preventable medical error—and was eerily similar to the 2006 events that transpired to sextuplets in Indiana, killing three.

Cedars Sinai is prominently displayed in the 60 Minutes piece and has received an abundance of negative press over the error. The thing about it, and the public is beginning to find this out, is that preventable medical errors happen quite often. In fact, the Institute of Medicine says 1.5 million people a year are injured as a result of medical errors. The Quaid’s have filed a lawsuit against Baxter, the maker of Heparin; to this point they have decided against filing a lawsuit against Cedars Sinai. The family is also starting a foundation to reduce medical errors.

I see a series of outcomes from this scenario: the call for higher quality in hospitals is only going to intensify. As Americans become more aware of the issues inside hospitals, the pressure for hospitals to rectify those issues will only increase. But here’s the problem: many hospitals will turn and run from transparency (yes, efforts to improve quality are happening everywhere, just not reported all the time), becoming even more secretive about avoidable mistakes to prevent the negative media onslaught that could occur.

That’s completely the wrong thing to do. The right thing to do is to start reporting everything publicly. More transparency is what is required here, not less. As I’ve written before, “increasing transparency not only helps consumers, it will make us better. And that should be the goal of being transparent: making ourselves accountable to ourselves.”

Megacommunities, solving health care (and other issues)

Serendipity is a wonderfully cool phenomenon.

On March 3rd I posted this where I posed the thought that health care problems should be solved locally.

And while I was trying to clarify my thinking on the whole matter, on March 7th the new ChangeThis Manifestos were posted and was immediately drawn to this one on “Megacommunities” by a few folks at Booz Allen Hamilton:

“Public, private, and civil leaders should confront together the problems that none can solve. Leaders everywhere no longer express as much confidence about the future as they once did. When they speak candidly, it often sounds as if they feel trapped in quicksand, unable to move forward easily. The methods and tools that helped them succeed in the past no longer work. The challenges they face—such as global competitiveness, health and environmental risks, or inadequate infrastructure—can no longer be solved by their organizations alone. And when they try to reach beyond the boundaries of their own corporation, government agency, or nongovernmental organization, there often is no clear pathway to success.”

Which led me to the book’s website.  And yesterday, the ChangeThis caretakers, had this review/information of/about the book on the 800-CEO-Read Blog.

Anyway, I’m running with this thinking.  While I’m not a big fan of the term “Megacommunities,” this concept is really powerful.  In order to compete globally, organizations, private business, and individuals will come together to solve the issues, together, at the community level (ahhh, health care!).  Working together is the only way toward true community sustainability.

9. The Paperless Hospital

We’re on the verge of an extreme infusion of information technology into hospitals across the country. Electronic medical records (EMR) are the future of inpatient and outpatient record keeping. I see three fears holding back many: 1) cost of implementation, 2) technophobia, and 3) concern about purchasing the “right system.”

While information technology is not the solution to all of our problems, when implemented and used correctly it can help reduce costs and allow for continuity of care amongst providers, ultimately benefiting the patient.

The announcement of the partnership between Google and the Cleveland Clinic moves us one step further (no matter how long it took us to take that step!) toward converting our system of paper to one that is electronic.

However, our own system will go a step beyond the EMR and will be a “paperless hospital.” Being paperless means, well, no paper. Beyond the EMR, going paperless has an impact on all aspects of the hospital. Some organizations have implemented paperless systems already allowing us to learn from what they have done. Newly constructed Dublin Methodist Hospital‘s paperless system is highlighted here. Read (it’s in the first paragraph) about the paperless Baptist Medical Center South.

Vanderbilt Children’s even has a demo to show us how easy it can be:


Principle 9: Paperless from the start! It is best for our patients. It is best for our organization. It is best for our health system. Removing waste and reducing errors are top priorities. We can do both by going paperless.

A Starting Point for Reform

You’ve read my thoughts on primary care before. Dr. Kevin Pho, of Kevin, M.D. blog fame, has an intriguing opinion piece in today’s USA Today. He says:

Primary care should be the backbone of any health care system. Countries with appropriate primary care resources score highly when it comes to health outcomes and cost. The United States takes the opposite approach by emphasizing the specialist rather than the primary care physician.

He also offers a terrific starting point for health care reform in this country:

It starts with reforming the physician reimbursement system. Remove the pressure for primary care physicians to squeeze in more patients per hour, and reward them for spending time with patients, optimally managing their diseases and practicing evidence-based medicine. Make primary care more attractive to medical students by forgiving student loans for those who choose primary care as a career and reconciling the marked disparity between specialist and primary care physician salaries.

Have a read.

The Macro View: Population’s Effects

PSFK had this a few weeks ago and and I saw it again yesterday from Richard Florida.

19.20.21. stands for 19 cities in the world with 20 million people in the 21st century.

The project: “19.20.21 is a multi-year, multimedia initiative to collect, organize and better understand population’s effect regarding urban and business planning and its impact on consumers around the word.  This 5+ year initiative will deliver results via 5 channels: web (including mobile), television (broadcast and cable), print (magazines, books and atlases), exhibits and seminars (virtual and onsite).”

Most of the people in the world live in cities, and by the end of this century many more will.  19.20.21. will conduct case studies on 19 cities around the world with populations of 20 million+ (only two in the U.S.: New York and Los Angeles) to study the effect of this population shift.

The site says “Any company with a focus on globalization will find the patterns and explanations in 19.20.21. indispensable.”

There are many items on the site that will impact on your life.  It’s worth looking at.  I can’t help but ask the question: how is this going to change health care?

While much of health care consumed by Americans is hardly international, that trend is growing.  Some dignitaries come to the U.S. to receive care.  Both those trends will have an impact: people are leaving to receive comparable care in other countries and as health care systems develop in other nations, fewer dignitaries are receiving care here.

This population shift will increase the specialization of American health care, especially in urban areas, as we strive for competitiveness on the global front (“we have the best health care in the world”).  It’s also going to force smaller hospitals in less densely populated areas to change their operations as well.  Maybe we’re moving to the Porter model of health care, where (real) competition reigns, care is delivered in patient-focused practice groups, and smaller hospitals deliver primary care and refer to the specialists at the large institutions.

Anyway, this is the start of the debate.  Any reform in the country needs to target the population’s needs at least 10 years from now…because it’s going to take us that long to figure out what we want; and add five years to that…to account for the “how” of implementation.